CQ - Patient Centredness

Introduction

Advance care planning (ACP) offers people the opportunity to plan their future care whilst they have capacity to do so and is supported by national guidance. Decisions regarding future care are more likely to be individualised and holistic when patients and their significant others are involved. This QI project aimed to address this by increasing the frequency of ACP discussions being offered and recorded on gerontology wards in an acute London Trust.

Method

A multi-professional steering group was established to improve ACP using PDSA methodology. A new ACP toolkit, training programme and electronic flowsheet (within the hospital’s patient record system) were implemented. ACP documentation quality was audited on gerontology wards pre and post implementation (over one to four months respectively). Data was compared using Pearson’s Chi-squared test.

Results

ACP flowsheets were completed by junior and senior doctors, and clinical nurse specialists in frailty and palliative medicine. The initial audit found disparity between documented topics of ACP conversations, with cardiopulmonary resuscitation recommendations being most discussed. Post implementation, 24 ACP flowsheets were reviewed, showing that more ACP topics were documented where these conversations were had; preferred place of death increased from 24% to 60% (p 0.011); treatment escalation plan increased from 41% to 75% (p 0.014); preferred place of care increased from 59% to 71% (p 0.066). Topics not showing significant improvement in documentation (despite inclusion in the flowsheet) were spiritual needs, information needs and prognostic discussion, broader social needs and what was most important to the patient.

Conclusion

The implementation of an electronic ACP flowsheet improved documented ACP conversations in some topics, guiding healthcare professionals to deliver care that aligns with peoples’ wishes and preferences. Documented conversations became easier to access, review and audit. Work is still needed to promote ACP conversations being centralised around what matters most to patients.

Introduction: The number of adults in the UK who identify as transgender is increasing, through greater recognition of trans identity and growing numbers of individuals transitioning in later life. The term “Transgender” encompasses a diverse range of experiences and identities, including those who identify as non-binary, gender-fluid, and gender-queer. However, within this review, we use the shortened term “trans” and the following broad definition: “people whose gender is different from the gender assigned to them at birth.” We conducted this exploratory review to examine the literature regarding the specific health and social care needs of older trans adults.

Methods: We utilised scoping review methodology and thematic qualitative analysis to systematically search and map the literature related to the physical and mental health challenges related to the ageing experience among trans adults in the UK.

Results: We identified 22 relevant papers through combined systematic search and additional manual reference review. We recognised five key themes within the literature: Systems and Structural Factors, Health and Mental Health, Social Care, Diversity and The Future. The former three themes relate to limitations presented by current models of care, barriers within services and potential areas for development. Key areas identified include challenges related to the application of a binary gender model within healthcare systems as well as advanced care planning and ensuring gender-affirming care where capacity is lost including living with dementia. The latter two themes identify gaps in the current literature and provide examples of trans-inclusive positive practice.

Conclusions: There is an ongoing need for researchers, clinicians and policymakers to ensure that the needs of older trans adults are studied, understood and accommodated within policy and practice. Service providers delivering care to older adults must understand trans-specific needs, particularly around advanced care planning, to ensure that trans people are supported to age well.

Background: NICE guidance for administration of dopaminergic medications is within thirty minutes of the prescribed time. Patients with Parkinson's Disease are frequent attenders of the ED, often leading to admission for a variety of reasons. Medication timing as an inpatient is frequently sub optimal, leading to potential harm of the patient and prolonged inpatient stays. Interventions previously seen to be beneficial include medication posters and alarms, tested across multiple wards at a different trust. This project aims to assess three interventions looking to improve the administration time of dopaminergic medication at Aintree University Hospital. Method: Three interventions were assessed: education, medication timesheets ad medication timers. These were assessed on one surgical and one medical ward. Baseline data was collected prior to implementation, then following each data was recollected. Nursing staff opinion and knowledge were also assessed using surveys at baseline, following education and at the end of the project. Results: Baseline data showed an average of 18.75% of doses given out of range on the surgical unit. Education proved to be useful, reducing the average to 12.5%. Medication timers were the most promising intervention, improving the average to 10.7%. However, when plotted on a control chart the changes appear unconvincing for significance. Surveys showed an initial reluctance for the use of timers, but following their use they then became the preferred intervention. Obstacles to their use were identified, such as loss of instructions and difficulty in changing the settings. Conclusion: This project has found evidence to support the use of medication timers to facilitate more accurate administration of dopaminergic medications. However further assessment is required with a follow up QI project given the uncertainty seen on the control charts.

Introduction: A BMJ study suggested that 1 in 5 sick, older patients have a ‘do not resuscitate’ document and a large proportion only had this completed in the Emergency Department (ED) (1). Current ED pressures could cause greater delay in this discussion, resulting in inappropriate cardiopulmonary resuscitation (CPR). The ReSPECT form was established to bring consistency to the communication of patients wishes, including ‘do not attempt CPR’ (DNACPR) (2). This QUIP assessed the incidence of inappropriate CPR in two ED’s by investigating the proportion of CPR performed on those with a prior DNACPR or ReSPECT form.

Method:

Data was collected retrospectively from cardiac arrests in two ED’s between the 1st of January 2023 and the 17th of November 2023. The three parameters assessed were the number patients undergoing CPR, number with prior DNACPR/ReSPECT forms, and how often CPR occurred within 30 minutes of patient arrival. Hospital A used ReSPECT forms, whereas Hospital B did not.

Results:

Over the assessed period, CPR was performed on 21 patients at Hospital A. Of these, 19% had prior DNACPR/ReSPECT forms and 43% of CPR was within 30 minutes of patient arrival. 10 patients received CPR at Hospital B. Of these, 0 patients had prior DNACPR/ReSPECT forms and 40% of CPR occurred within 30 minutes of patient arrival.

Conclusion:

Hospital A performed CPR on more patients with prior DNACPRs compared to hospital B. Occasionally, these DNACPRs were on the GP portal but were not easily accessible in the hospital setting due to the hospital’s paper-based notes system. Both sites performed CPR on a similar proportion of patients within 30 minutes of admission. This highlights the importance of prompt decisions, communication and the need for community discussion with documentation that is easily accessible across healthcare settings.

Background: ‘IN REACH’ was established, having identified a significant need to improve nutrition for cognitively and physically frail hospital inpatients, admitted to the Complex Medical Units (CMU) at the John Radcliffe Hospital. The IN REACH team includes the CMU multi-disciplinary team (MDT), representatives from patient and volunteer groups, caterers and medical illustrators.

Introduction: IN REACH identified that food and drink is often unreachable by inpatients. The project’s aim is to ensure food and drink is always within patient reach, improving nutritional intake, avoiding dehydration, reducing weight loss, reducing family anxiety, promoting independence and improving health outcomes.

Method: MDT members, patients and their families were engaged in the design. Baseline observational data included whether both food and drink were in reach and whether the patient had cognitive impairment. Interventions to be evaluated by Plan-Do-Study-Act (PDSA) methodology include: raising awareness at daily MDT meetings; focussed education by presenting observational data to catering team; involvement of volunteers; the introduction of IN REACH champions; and prompting by signage, both physical and digital. Improved inpatient nutrition will be correlated with data on length of stay and health outcomes. Improved rates of return to baseline function and independence are anticipated, by keeping food and drink, in reach.

Results: Baseline data showed out of 319 inpatients, only 33% had both food and drink within reach. 67% had cognitive impairment and only 27% were able to reach food and drink. Following 4 initial PDSA cycles 58% of patients had food and drink within reach.

Conclusions: Most CMU patients have food and drink left out of reach. Patients with cognitive impairment are particularly at risk. Changing ward culture is challenging. Further and repeated interventions are necessary.

Introduction: Delirium affects up to 50% of older individuals within hospital environments, with a notable occurrence in 30% of those aged 65 and above in emergency departments. This QIP aimed to enhance the early recognition of delirium by implementing the 4AT assessment and optimize assessments and investigations by implementing the Delirium Bundle.

Methodology: A survey involving 39 doctors was conducted to evaluate their comprehension of delirium and awareness of the Delirium Bundle. PDSA 1 involved retrospective data analysis of medical records for patients admitted with delirium and used as a preliminary baseline to evaluate how the delirium bundle is being utilized. PDSA 2 integrated multiple teaching sessions and the implementation of the Delirium Bundle, assessing the effectiveness of these interventions.

Results: In PDSA 1, twenty-nine patients were identified. None of the patients had a 4AT assessment done. Twenty patients (69%) had a hematological screen done, eight patients (27%) had an ECG done, twenty patients (69%) had a CXR done, eighteen patients (62%) had an MSU test done, eight patients (28%) had cultures done, and twenty-three (79%) had a CT head scan done. In PDSA 2, thirty patients were identified. Seven patients had a 4AT assessment done, sixteen patients (53%) had a hematological screen done, nineteen patients (63%) had an ECG done, twenty-two patients (73%) had a CXR done, fifteen patients (50%) had an MSU test done, fourteen patients (47%) had cultures done, and 20 patients (67%) had a CT head scan done.

Conclusion: The implemented changes showed effectiveness with increased 4AT assessments and enhanced confusion screening. Improvements in assessments and investigations for diagnosed delirium patients were evident. To further enhance efforts, future initiatives include incorporating the 4AT assessment in clerking booklets, conducting continuous teaching sessions, and displaying posters in relevant wards.

Wipes are a practical solution for cleansing skin and widely used in children, neonates, and in geriatric care. Some wipes contain compounds may cause dryness, itching, irritation, and inflammation. This abstract looks at the efficacy of wipes that do not contain multiple unnecessary added ingredients. 

Frailty is defined as a state of increased vulnerability to poor resolution of homoeostasis after a stressor event, increasing the risk of adverse outcomes (1). The Clinical Frailty Scale (CFS) is a validated infographic tool used to assess frailty in clinical settings (2). It aims to provide a standardised framework for frailty assessment, however determining the CFS is primarily subjective in nature, relying on clinical judgement and observation. NHS Elect have launched a CFS application, helping to improve the objectiveness of the CFS outcome. A quality improvement project performed at Royal Surrey Foundation Trust explored the difference in the CFS calculated by junior doctors from Non-Geriatric specialties and referred to the Inpatient Older Person Advice and Liaison (iOPAL) team, compared with the CFS calculated by the iOPAL team using the CFS application. The audit showed 27% of referrals had no CFS provided, despite it being a referral criterion, 20% had the same CFS score, 30% had an over scored CFS and 23% had an underscored CFS. The iOPAL team updated the referral form to include advice on how to calculate the CFS and included webpage and QR-code links to access the CFS application. In addition, direct verbal feedback and education was provided. Since the interventions, an improvement of CFS calculations has been seen with a repeat audit showing a reduction of referrals not providing a CFS to 17%, an increase having the same CFS score to 34% and reduction of underscoring CFS to 9%. Over scoring of CFS remained an issue at 40%. In conclusion, education around CFS and use of the CFS application has led to improved CFS scoring by junior doctors from Non-Geriatric specialties. Further micro-learning sessions are being developed to target clinicians of all grades from Non-Geriatric specialties, in particular surgical specialties.

Introduction: BPPV is a condition characterised by the displacement of the calcium crystals within the vestibular system. Whilst BPPV itself is not life-threatening, symptoms can cause complications and lead to falls, injuries, and in severe cases, head injury. The diagnosis and treatment for BPPV are manoeuvres, which in some patients especially the elderly cannot be performed adequately leading to untreated BPPV. This study aims to assess whether patients are being affected by frailty factors and comorbidities which is hindering their treatment.

Methods: This study was part of a prospective service evaluation done at Guys Hospital Balance Clinic. The research focused on collecting details from patients receiving care at the vestibular clinics, focusing on their history, current treatment, and future plans regarding BPPV.

Results: 52 patients were recruited for this study with an average age of 67.23. Out of 47 patients who had positional testing, only 33 were successful with 50% of the remaining being limited due to pain, 25% reduced neck range, 12.5% were apprehensive, 6.25% had reduced mobility and 6.25% had further contraindications. 43 patients had the PRM attempted, 8 had declined and 12 were unsuccessful. 30.77% of the patients had a mechanical restriction of reduced neck range, and a further 28.57% had pain that limited them from the PRM. 23.08% of patients had reduced mobility and 15.38% were apprehensive.

Conclusion: The average age of this sample size was 67.23 and nearly one-fourth of the patients had fallen in the last year and 16% had either minor or major Injury. In total 32.69% of patients experience frailty factors or other comorbidities which is preventing them from receiving full treatment for their BPPV. This study has shown the impact that frailty factors such as neck pain, reduced mobility, apprehension, etc can have on both positional testing and the PRM.

INTRODUCTION Dementia in Parkinsons is common and under-recognised with a significant impact on person and their carer. Contrary to other services, Cardiff and Vale Parkinson's services run an integrated Parkinson's clinic where People with Parkinsons (PwP) developing dementia continue to be managed by the same clinical team.

METHODOLOGY An review of 425 patients diagnosed with dementia with a background of Parkinson's over last 10 years was undertaken. A random sample of 50 patients assessed for demographics, duration of Parkinson's, presentation of dementia and outcomes including place of residence and mortality data. RESULT Of 50 patients, the majority were male (28) with mean age of 75 years. The mean duration of Parkinson's prior to diagnosis of dementia was 6 years and from PD Dementia to death 3 years. The Median Clinical Frailty score on the diagnosis of dementia was 5. Pre-dementia diagnosis, there were no patients in care settings with 50% independently living at home, and the other half dependent on care support. Following dementia diagnosis, only 1 patient was living independently at home, with 19/50 (38%) in care facilities and 30/50 (60%) living at home with support. There was a trend towards increasing hospital admissions and increased need for support from the Parkinson's team following dementia diagnosis (pre-diagnosis 24 admissions, post-diagnosis 31 admissions) increased contact to Parkinson's team (323 versus 360).

CONCLUSION The onset of dementia appears to mark a significant shift in disease burden resulting in an increased rate of institutionalisation and care needs. The trend towards increasing hospital admissions in this cohort alongside increasing contact with the care team reflects increasing frailty, carer and disease burden. The onset of dementia should be a trigger for clinicians and service providers to proactively plan for future care provision. This needs further evaluation and we are analysing our wider sample currently.