CQ - Patient Centredness

In 2022 we had a unique opportunity to develop a Geriatric service in Totnes Community Hospital after a long-standing GP led service provision ended. Given the fact that the majority of patients in the Community Hospitals were over the age of 65 and many had multiple co-morbidities or presented with a frailty syndrome, it was felt that the Geriatric department was the most suitable specialty to take over the service provision. Method Over a period of 12 months, we have gradually introduced key aspects from the Comprehensive Geriatric Assessment (CGA) to the care of our patients. Every new patient had a CGA on admission, completed by the clerking doctor with support from the MDT. We have concentrated on identifying and managing falls risk, bowel and bladder care, bone protection assessment and reviewing inappropriate polypharmacy. Through collaboration with our community pharmacist and nursing staff we have introduced additional medication administration services to include intravenous bisphosphonates, monofer infusions, medical hyperkalaemia management and intravenous electrolyte replacements. For our frailer patients we looked at prioritising care in the community, and closer to their home and family. Where appropriate and safe, we kept the patients in the community hospital for both acute illness and end-of-life care, instead of re-admitting them back to the acute hospital. Conclusion Over the year we have trained, upskilled and supported our nursing staff in managing and treating more acutely unwell and complex patients, so that we can provide more comprehensive and holistic care to our frailer patients in a community setting. We have prevented numerous re-admissions back to the acute hospital by being able to provide increased level of medical care. This was particularly important for the many patients with advanced dementia and delirium. The current model of care is still ongoing and continuing to develop.

Background: This project is based in the geriatric department of Wye Valley NHS trust which serves Herefordshire and mid-Powys.

Introduction : In frail, older patients, cardiopulmonary(CPR) resuscitation has low rates of success. Lack of appropriately completed ReSPECT forms leads to futile attempts of CPR, repeated readmissions and patient harm. This project aims to improve patient centred advance care planning (ACP), and the quality of their documentation in the ‘clinician recommendations’ section in ReSPECT forms through development of new educational tools.

Methods: The Supportive and Palliative Care Indicator Tool (SPICT) was used to identify patients benefitting from ACP in the department. Data was collected on how many patients had ReSPECT forms and how well they were completed against standards adapted from the Resuscitation Council guidelines. Plan-Do-Study-Act(PDSA) cycle 1 was completed developing an aide-memoire (ReSPECT tool), and an interactive workshop. PDSA cycle 2 lead to design of the project poster titled ‘Revamp your ReSPECT discussions’ which was displayed on the wards, and shared on social media. PDSA cycle 3 was conducted to measure response and aid direction. Results: PDSA 1 showed 71% patients meeting SPICT criteria had ReSPECT forms. This improved to 82% by PDSA 3. PDSA cycle 1 revealed that only 32% of ReSPECT forms were completed to audit standards, by PDSA 3 this improved to 43%. The project received engagement from the wider healthcare community on Twitter/X where the project poster garnered over 36,600 views and has been shared in the trusts latest issue of safety bites.

Conclusions: Our work led to an improvement in the quality of documentation and illustrated a novel approach to communicating the standards expected when delivering patient-centred ACP. The interest received via social media highlighted the importance of sharing this experience. We plan on building on this success through wider communication of the standards.

Introduction

High-dose corticosteroids have significant benefits for infective exacerbations of COPD, reducing risk of relapse, length of hospital stay and earlier symptom improvement. However, recurrent use has been shown to increase risk of comorbidities including osteoporosis, type two diabetes mellitus (T2DM), cardiovascular disease, hypertension, and elevated body mass index (BMI). 

This audit assessed how many patients at Anchor Mill Medical Practice in Paisley, who had been prescribed two or more courses of prednisolone in the six months prior to the start of data collection, had been assessed for T2DM, renal impairment, elevated BMI, hypertension and osteoporosis within the previous year. 

Methodology 

An EMIS search was performed for patients over eighteen who were coded as having COPD and who had received two or more acute prescriptions of prednisolone from 03/04/2023 to 03/10/2023. 

Data was then collected from the patient's medical summaries and investigations, looking at if they had had HbA1c, urea and electrolytes, lipids, BMI and blood pressure checked within the preceding year. The audit also looked at how many patients had had a QFracture score calculated over the past year, or if they had been referred for or had had a DXA scan within the previous five years. 

Results 

Over 50% had had their lipid profile and HbA1c checked, with over 75% having had their U+Es, BMI and BP checked. The major outlier was OP risk assessment, for which only 31.25% of patients had been screened. 

Conclusions 

Within this primary care setting, improvements could be made on screening for associated comorbidities with COPD. The patients were referred for these investigations, with the biggest improvement being a 140% increase in patients referred for a DXA scan, and annual follow up with the practice nurse was changed to include these investigations as appropriate.

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.