CQ - Patient Centredness

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.

Introduction 

The British Geriatrics Society advocates for the development of local protocols to address frailty (1). A Cochrane Review on the use of Comprehensive Geriatric Assessment (CGA) resulted in higher survival rates at 3 months and fewer admissions to nursing homes at one year following hospital admission (2). Key components of CGA, including Treatment Escalation Plans (TEPs), Universal Care Plans (UCPs), Clinical Frailty Scores (CFS), and Abbreviated Mental Test (AMT) play pivotal roles in identifying frailty, establishing timely end-of-life care plans, preventing future inappropriate admissions, supporting early discharge and detecting cognitive impairment.  

Methods 

A retrospective analysis of documentation of 4 GCA parameters (TEP, UCPs, CFS, AMT) on admission to an Elderly Care ward over 2-weeks was conducted.  An intervention was introduced which included the development of departmental posters; training medical staff and a frailty proforma, following which a second audit cycle was performed.  

Results 

Cycle one (N=34): Demonstrated poor documentation of CGA parameters. TEP completion 100 % (34/34), Day 2 TEP Completion 64% (19/34), UCP present 21% (7/34), CFS 12% (4/34), AMT completed 15% (5/34).  

Cycle two (N=24). Documentation improved across all parameters. TEP completion 100 % (24/24), Day 2 TEP Completion 100% (24/24), UCP present 29% (7/24), CFS 58% (14/24), AMT completed 58 % (14/24). The proforma was used in 54% (13/24). 

Conclusions 

The use of a frailty proforma, visual aids and teaching is useful in improving documentation of frailty assessments. All parameters showed significant improvement in documentation when the proforma was used.  This tool could be extended to include more data points in a CGA and would be useful to implement across the department to create uniformity, ease of access to information and improve management of elderly patients. 

References: 

1. British Geriatrics Society (2014). Fit for Frailty.  

2. Ellisa et al. Cochrane Database Syst Rev. 2017 Sep 12;9(9):CD006211. 

Introduction

Improvement project in response to several bereavement meetings with families reporting concerns with communication and care received during their loved ones’ end of life care (EOLC).

Methods

Retrospective review of 79 inpatients documentation who died between August 2021-March 2022 in comparison against the Royal College of Physicians National Care of the dying audit to identify targets for intervention. Survey of 22 members of ward staff between (January-March 23) including medical, nursing, and allied health professionals to understand confidence, clinical knowledge and available resources to care for EOL patients and families.

Results

Retrospective audit showed 13.9% of families expressed concerns about EOLC received. Discussions held of the potential for progression into EOLC were 82.4% of cases and that of approaching the terminal phase of life 83.5% which is similar to the national findings of 83% and 79% respectively. There was an absence in offering holistic support to families and patients like food vouchers, parking permits, and referral to chaplaincy team at only 27.8% cases. This theme was seen in the staff survey, with 16.5% of staff suggesting offering parking permits and 15.2% suggesting food vouchers. The survey also highlighted the relative lack of confidence of allied health professionals 5.9/10 vs the remaining team average of 8.1/10 when providing EOLC.

Conclusions

The audit and survey identified gaps in patient care and communication for our ward staff. To improve quality of care, teaching sessions in collaboration with palliative care team are set to start for ward staff. To improve communication, end-of-life board was set up as visual aid for staff, patients and family as well as a proforma to standardise death verification documentation across the trust. These are first cycle interventions to help improve patients and families holistic.

Introduction: The World Falls Guideline 2022 recommends that measurement of lying-standing blood pressure (LSBP) is an integral part of the multifactorial falls risk assessment (1). Pre-intervention less than half of eligible patients had a LSBP recorded and documented. The aim was to improve the recording and documentation of LSBP for adults aged 65 and over admitted with a fall or at high risk for falls. Method: All patients aged 65 and over admitted with a fall or identified as at high risk for falls to a care of the elderly ward were included over the period of 15th September 2023-15th November 2023. Royal College of Physicians (RCP) guidance (2017) for standard measurement of LSBP was used (2). Data was collected on electronic spreadsheets from electronic observation charts. Two plan-do-study-act (PDSA) cycles were conducted. Firstly, ward posters demonstrated how to record and document LSBP. Secondly, ward-based one-to-one teaching interventions using RCP LSBP lanyard flashcards (2) were conducted. Results: Following cycle one, 50% of eligible patients had LSBP documented. Following cycle two, 80% of eligible patients had LSBP documented. Following two PDSA cycles, there was a 37.1% increase in the average number of eligible patients who had LSBP correctly recorded and documented. Conclusion(s): Interventions of aide memoirs and education for nursing and medical staff improved the recording and documentation of LSBP. Indications and correct measurement guidance for LSBP should be included in future ward staff induction information and departmental teaching sessions.

1) Montero-Odasso, M, Van der Velde N, Martin FC et al. The Task Force on Global Guidelines for Falls in Older Adults , World guidelines for falls prevention and management for older adults: a global initiative, Age and Ageing, Volume 51, Issue 9, September 2022. 2) Measurement of lying and standing blood pressure: A brief guide for clinical staff. 2017. https://www.rcplondon.ac.uk/projects/outputs/measurement-lying-and-stan… 

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:

Delirium is a common condition in hospitals, especially among older people. This refers to a dramatic decline in mental capabilities marked by diminished concentration and consciousness.

Aims:

The purpose of this study is to assess the views, knowledge, and behavior of non-consultant hospital doctors about managing delirium in a large Irish hospital. Methods: Questionnaires were given to 28 healthcare professionals from various departments according to Davis and MacLullicin (2009). It was conducted between July and September 2023 with emphasis on finding out its prevalence rate, diagnostic criteria, and management strategies for delirium.

Results:

The study established that majority of the respondents recognized the importance of delirium but there appears to be a gap in practical management of this clinical syndrome. Although many doctors agreed that delirium was significant, most lacked confidence in diagnosing as well as managing it. The use of standardized assessment tools like the 4AT was limited.

Conclusions:

This study highlights the disparity between what is known and practiced by hospital doctors concerning delirium care. It implies increased training for delirium management with frequent use of assessment tools and ongoing education aimed at enhancing patients’ outcomes during cases of delirium. Keywords:Delirium Management, Hospital Doctors, Medical Training, 4AT, Clinical Practice, Elderly Care.

Introduction: The terminology surrounding manual-handling equipment and discharge planning is rarely taught in medical school. Yet, it is crucial for medical staff, particularly those working on Care of the Elderly (COTE) wards, to comprehend these terms to accurately assess a patient's function and optimise discharge planning.

Methods: A 17-question survey was distributed to establish the baseline knowledge of medical staff in a district general hospital, with the aim of using PDSA (plan, do, study, act) cycles for improvement as needed. Following preliminary data analysis, a lunchtime hospital teaching session was designed to educate individuals on these key terms and equipment. Ten clinicians attended and took part in a mentimeter quiz reassessing knowledge post-teaching.

Results: Seventeen participants, ranging from physician associates and junior doctors to consultants, completed the initial survey anonymously. Knowledge varied widely, with scores ranging from 15% to 91%. All participants accurately identified a Zimmer frame, 15 (88%) correctly labelled a PAT slide and 13 (76%) a hoist. Reassuringly, all knew that the acronym “POC” stood for Package of Care. Poorly recognised equipment included turn discs, standing hoists and hover jacks. Furthermore, the term “reablement” and the healthboard-specific “complex needs booklet” lacked clear definitions. While many participants could define fast track discharge, they could not distinguish between the two types. The average score per question increased from 53% in the pre-teaching survey to 59% post-teaching, however this was not statistically significant (P=0.57).

Conclusions: Although medical staff were familiar with certain equipment, they lacked understanding of more specialist aspects of discharge planning and less commonly used equipment. Unfortunately, these results did not significantly change post-teaching, likely due to low attendance; however, we are hopeful that the survey distribution and teaching will spark discussion throughout the hospital. We have now adapted the teaching content into posters for the next PDSA cycle. 

Background

Fragility fractures, defined as fractures resulting from low energy trauma (1), are consistent with a diagnosis of osteoporosis. When a patient is discharged from hospital, guidelines recommend principal and additional diagnoses, relevant co-morbidities contributing to primary diagnosis, medications and relevant investigations are recorded (2).

Methods

This audit reviewed discharge summaries of all patients discharged from a rehabilitation unit over two months, in accordance with the Health Information and Quality Authority’s (HIQA) National Standard for Patient Discharge Summary Information (2). Patients with fragility fractures were identified through medical record review. Principal and additional diagnoses were reviewed, with cause and mechanism of falls considered relevant co-morbidities. Discharge prescriptions for anti-resorptive medications were noted. Dual-energy x-ray absorptiometry (DXA) was recorded as a relevant investigation (3).

Results

33 discharge summaries met inclusion criteria. 12 patients were admitted with fragility fractures with a mean age of 81 years (69-90). 83.3% (n=10) were female. Osteoporosis was mentioned in 50% (n=6) of discharge summaries of patients with fragility fractures. On review of relevant co-morbidities, likely cause of the fall was documented in 58.3% (n=7) and mechanism in 75.0% (n=9). Bone protection was planned in 83.3% (n=10). Plan for DXA was documented in 8.3% (n=1)

Conclusion

This audit demonstrates suboptimal communication between hospital and community teams, despite chronic disease being predominantly managed in the community. In Europe, Ireland has one of the largest disease burdens relating to osteoporosis and the largest increase predicted in the next ten years (4) . It is of utmost importance we improve communication to minimise disease burden.

References

1. International Osteoporosis Foundation (2023) Fragility Fractures. https://www.osteoporosis.foundation/health-professionals/fragility-frac… (Accessed on 30 August 2023).

2. Health Information and Quality Authority (2013) ‘National Standard for Patient Discharge Summary Information’. Dublin: Health Information and Quality Authority. https://www.hiqa.ie/reports-and-publications/health-information/nationa…- patient-discharge-summary-information (Accessed on 30 August 2023).

3. Irish Osteoporosis Society (2023) About Osteoporosis. https://www.irishosteoporosis.ie/information-support/about- osteoporosis/#accordion-0-10 (Accessed 30 August 2023).

4.Carey, J.J., Erjiang, E., Wang, T., Yang, L., Dempsey, M., Brennan, A., Yu, M., Chan, W.P., Whelan, B., Silke, C., O'Sullivan, M., Rooney, B., McPartland, A. and O'Malley, G. (2023), Prevalence of Low Bone Mass and Osteoporosis in Ireland: the Dual-Energy X-Ray Absorptiometry (DXA) Health Informatics Prediction (HIP) Project. JBMR Plus, pp. 1-10.

At University Hospital Monklands, a district general hospital in Lanarkshire, an ED in-reach pilot was set up to deliver the best possible outcomes for frail older adults by proactively reducing unscheduled admissions, thereby reducing the time they spend in the hospital.

Aim

To reduce unscheduled admissions for patients with a clinical frailty score (CFS) ≥ 6, admitted to ED between 8am – 3pm, Monday to Friday, by 50%. Method An ED Frailty MDT was formed, comprising of Acute Care of the Elderly (ACE) nurses/ Advanced Nurse Practitioners (ANP) and Consultant Geriatricians. Patients ≥ 65 years with a CFS ≥ 6 likely to be discharged on the same/next day were identified by ED staff and referred to ANP/ACE nurses. A Comprehensive Geriatric Assessment (CGA) was performed by the nursing team within 30 minutes of the referral, with the support of the consultant geriatrician. Data was collected on number of patients seen, time taken before review and patient outcomes.

Results

97 patients were reviewed at the ED by the team within a 4 – month period (October 2023 – January 2024). 53.6% (52/97) of them were discharged, either directly home(32) or with a referral to the Hospital at Home service/Home Assessment Team (20).

Conclusion

The pilot had three tests of change with variable results. The volume of calls from ED staff improved after the first and second tests of change (which involved increasing visibility of the ANP/ACE nurses in ED and having the consultants accompany them for reviews respectively) but a sharp drop was noted after the third test of change. There was also the challenge of staff shortages but despite this, the pilot was well received by the managers and staff in ED and further work is being planned on how to establish the gains of the project.