CQ - Patient Centredness

Introduction Swansea Bay Health Board is covered by eight community clusters (240 virtual beds), each with their own Virtual Ward (VW) MDT which provides community based Comprehensive Geriatric Assessment and reablement. The VW governance structure includes the routine collection of person centred metrics. There is no recognised PROM or PREM specifically designed for needs of frail older people and PROMs and PREMs are rarely used to inform quality and continuity in services at transitions of care (e.g. at discharge from hospital) Methods VW data from June 2023 to February 2024 was analysed. Patient-reported outcomes and experiences (PROMS and PREMS) were collected by the VW team at set timepoints in the patient journey. Data was collected using the PRO-MAPP digital interface ensuring inter-user consistency. Results 1858 VW patients, 1094 (58.9%) female, median age 86 years. The majority, 1044 (56.2%) were referred from secondary care, primarily from acute frailty services, with the remainder identified by primary care. In total, 418 PROMS and 344 PREMS were collected. PROMS - Reported improvements in mobility, self-care, usual activities, pain and anxiety & depression (p001 after vw input. prems – the majority of patients found had been explained well prior to referral (84.0%), were contacted promptly (95.6%), staff professional and friendly (100%), provided patient-centred care (94.2%), contactable (92.4%), glad they avoided or reduced length hospital admission (95.3%). when speaking with 72 care-givers, happy patients' needs met (100%) positively impacted their lives as carers (90.1%). discussion there was high patient care-giver satisfaction service. prom data suggested a significant positive impact on outcomes. not all referred have sampled which is missed opportunity variability between collection clusters. 

Parkinson's Disease (PD) is a progressive neurological disorder for which there is currently no cure.  Palliative care should be discussed as part of PD management, both to empower patient understanding and expectations of their condition and to avoid unnecessary hospital admissions

Results from the 2022 Parkinson’s UK national audit,  found that the elderly care PD service in York was underperforming in having advance care planning (ACP) discussions with PD patients. The aim of this quality improvement project is to further review ACP discussions on a larger sample size and improve practice in this area.

Our sample included 100 people with idiopathic PD within the Vale of York who had been seen by a PD specialist in the month of November. Clinic letters from all PD specialist involvement were read, alongside any letters from other specialities, discharge letters from hospital and general practice encounters to look for any documentation of ACP discussions.

Results showed that 82 patients had no documentation of any discussions on ACP. This population included patients in nursing homes, needing package of care, patients with Rockwood frailty scores >6 and patients showing signs of deterioration in their condition.

It is clear from the data that these discussions are not occurring as often as they should.  Simply doing this QIP has raised awareness within the team and anecdotally, improvement in performance has already been noted.  Further discussion and presentation of the QIP findings are to be presented at clinical governance meetings to provide further education.  Data will then be reaudited. 

Further change options following discussion and education could include clear documentation strategies for ACP helping to link between primary and secondary care. It should be noted that our service does not provide a Parkinson’s nurse who would often instigate ACP discussions.

Introduction Many patients admitted with fragility femoral fractures have established cognitive impairment but no formal diagnosis of dementia. This lack of pre-existing diagnosis impacts care, counselling and discharge planning. This audit assessed how many people aged >65 admitted with a fragility fracture had information, at the time of admission, suggesting a likely but unconfirmed diagnosis of dementia and how their length of stay (LOS) and discharge destination compared to patients with confirmed dementia.

Methods 47 consecutive patients aged >65, admitted with a fragility femoral fracture had their electronic care records reviewed to identify information suggesting the presence of cognitive impairment/dementia. 30-day mortality, LOS and discharge destination was compared for three groups, 1) dementia, 2) informal dementia diagnosis and 3) no evidence of cognitive impairment.

Results Of 47 patients reviewed, 35(74%) were female, mean age 80.6 years (range, 68-94). Of these, 7/47(15%) had an established dementia diagnosis (mean age 82.4 years), 9/47 (19%) had unconfirmed cognitive impairment/dementia but without a formal diagnosis (mean age 82.2years) and 31/47 (66%) had no evidence of cognitive impairment(mean age 79.7 years). In cases of confirmed dementia diagnosis, the mean LOS was 54.7 days (range, 16-114). One patient died 1/7 (14.3%) and 3/7 (42.9%) were discharged home. For patients with an informal dementia diagnosis, the mean LOS was 35 days (range, 7-74). Two patients (2/9) died (22.2%), and 3/9 (33.3%) were discharged home. For those with no cognitive impairment, the mean LOS was 36 days (range, 7-92). Three patients 3/31 (9.7%) died, and 22/31 (71.0%) were discharged home.

Conclusion A significant minority of patients had likely undiagnosed dementia, with mortality and discharge destinations similar to patients with recognised dementia. Services need to consider how best to identify and diagnose cognitive impairment/dementia at the time of admission for fragility fractures.

Same Day Emergency Care (SDEC) at St James’ Hospital, Leeds provides urgent care at the interface between primary and secondary care, offering comprehensive geriatric assessment (CGA) to those living with frailty, aiming to prevent hospitalisation and delay frailty progression. Advance care planning (ACP) is a vital component of prioritising care preferences including at end-of-life, but timing often falls short in practice. This quality improvement (QI) initiative aims to proactively open ACP discussions, allowing patients to consider their care goals, ensuring our care is aligned with their priorities.

Between July 2022 and April 2023, the project involved 1039 patients. Led by Advanced Clinical Practitioners with support from consultant geriatricians and a palliative care specialist nurse, ACP discussions were encouraged through prompts in daily staff huddles and drop-in teaching sessions. ACP uptake increased from 7.8 % to 19.3%. Insights from a perception survey involving 83 healthcare professionals revealed key barriers including clinical workload, limited space, lack of experience and confidence as well as prognostic uncertainty and patient factors. Education and training, clinical supervision, patient information leaflets and a conducive environment were positively associated with ACP.

There has been a cultural shift in the department as the practitioners now routinely prompt staff to undertake ACP in safety huddles. Key catalysts for ACP initiation were found to be progression of frailty, terminal diagnoses, dementia, and recurrent hospital admissions. As a new SDEC unit is scheduled to open in the coming months, with provision of space and privacy, our aim is to improve the quality and quantity of ACP discussions with the patient at the centre of all decision-making. In line with these endeavours, parallel support within the community through our home (virtual) ward will further enhance proactive care planning in older people living with frailty.

Introduction: NICE guidance recommends that clinical teams should identify patients who are approaching their final year of life. It advises using tools such as the Clinical Frailty Score (CFS) to identify this cohort. Wigan has a significant proportion of severely frail patients would would benefit from this conversation. The aim of this project was to increase the percentage of patients with severe frailty who have an advanced care planning (ACP) conversation during their hospital stay. Method: Retrospective data collected from discharge letters was used to identify patients aged >65 years with a CFS ≥7 Astley ward. Exclusion criteria included patients <65 years old, patients who died during admission, patients who moved wards prior to discharge and re-admissions if within 30 days. The cohort was examined to see if firstly they had been highlighted as a patient who would benefit from ACP, and if an aspect of ACP had been completed during their admission. Results: 10 PDSA cycles were completed over the two years (2021-2023). Our data showed that teaching on ACP and dedicated Registrar sessions on the rota had the greatest impact on improving the completion of ACP discussions. While unified method of CFS assessment on admission and documentation of ACP on shared platforms did not change the ACP uptake significantly. Conclusions: Systematic approach to improving ACP in severe frailty has the potential to improve patient experience and allow them to highlight their wishes at the end of life. Despite trialling multiple activities to increase ACP uptake it was clear whole multidisciplinary team engagement is required to maximise ACP. Therefore, future cycles will examine the impact of implementing a focused approach to ward rounds. Although we have progressed towards our goal, more work needs to be done to maximise uptake of ACP for severely frail patients during hospital admissions.

Introduction: In the cancer setting, Comprehensive Geriatric Assessment (CGA) reduces chemotherapy toxicity, improves QOL and increases advance directive completion (ASCO 2020: The Geriatric Assessment Comes of Age; Soto-Perez-de-Celis et al; The Oncologist). We wanted to look at whether CGA improved symptomatology, as patients attending our oncogeriatric clinic complained of a range of symptoms, related to their cancer, as well as other co-morbidities and frailty.

Methods: We retrospectively analysed follow up clinic letters of patients who had attended the oncogeriatric clinic, between June 2022 and June 2023. We used a Lirkert scale, to see whether symptoms they had complained of had 1 – got worse, 2 – stayed the same, 3 – improved or 4 – resolved.

Results: 32 patients with a wide range of malignancies were included. 59 patients were excluded because they: died before the 2nd appointment, did not require a second appointment, had their second appointment outside the analysis window, DNA or in 1 case the follow up letter could not be found. On average each patient complained of 3 symptoms. 30 different symptoms were noted (2 excluded as there was no mention of them in the 2nd visit.) The top presentations were pain, constipation, low mood, breathlessness, reduced mobility, falls and dizziness. 68% of the symptoms complained of showed improvement – including all the top presentations. The average score on the Lirkert scale was 2.76 78% of patients had shown improvement or resolution in at least some of their symptoms.

Conclusions: Our retrospective review shows that older, cancer patients, have a high burden of varied symptomatology, because of their cancer, co-morbidities and frailty. Attendance at an oncogeriatric clinic results in improvement in the symptom burden for the majority of older adults, and an improvement in some symptoms, whether they are related to cancer, or other frailty syndromes.

Introduction

The UK Parkinson's Audit assesses whether patients with Parkinson's Disease (PD) are managed according to standards. Referring patients to physiotherapy (PT) and advising those with daytime sleepiness not to drive are two of these. In our clinic, patients identified as drivers are advised to inform the DVLA and will undergo a MOCA, sleep questionnaire and driving assessment. 

Project Aim

Are we making early physiotherapy referrals and documenting driving status in new diagnosed outpatients? 

Methods

Online notes of newly diagnosed patients over a 12 month period were reviewed. A clinic checklist was created and displayed in the clinic as a poster with the mnemonic:

Lasting Power of Attorney

Driving

Osteoporosis

Physiotherapy

Anticipatory Care Planning

Following introduction of the checklist a further cycle has taken place. 

Results

In the initial cycle, 34 newly diagnosed patients were identified. 4 were nursing home residents and excluded from results. Of the remaining, 83% had documentation of driving status. 2 patients were drivers and 1 had evidence of completed driving assessments. 20 patients were referred to physiotherapy and a further 3 were offered (76%). 50% of referrals were within the first month of diagnosis. Following checklist introduction, 21 new PD patients were identified over 6 months. The clinic team were sent updated data throughout to encourage ongoing improvements. 95% had documentation of driving status. 9 were drivers. 6 had full driving assessment completed. 16 (76%) patients were referred to physiotherapy. 75% of these were referred within the first month. 

Conclusions

Repeat data collection has shown improvement in both driving status documentation and early physiotherapy referral. The checklist reminds us of important aspects of outpatient care in PD that may otherwise get forgotten. Ongoing data collection will hopefully continue to improve. 

Introduction

Although hearing loss is the foremost cause of years lived with disability in people over 70, it remains commonly underrecognised ^[1,2]. Health of the UK signing deaf community is reportedly worse than the general population, often due to resulting undertreatment of associated co-morbidities including visual impairment, falls and dementia ^[3,4].

Local Problem

There is an estimated 21% prevalence of ≥25dBHL hearing loss within the Wolverhampton adult population, this increasing with age ^[5]. A large number of inpatients admitted to the Older Adult Medicine (OAM) wards at New Cross Hospital have clinically evident sensory impairment, impacting upon interactions with healthcare staff. This project identified the current methods through which hearing and/or visual impairment is formally screened for and documented within the OAM Department of a large district general hospital, targeting interventions towards mitigating barriers faced in sensory assessment.

Methods and Intervention

Baseline and post-intervention documentation of sensory impairment was collected from admission and bedside notes of 23 inpatients during each cycle. A multidisciplinary focus group of medical, nursing and practice education facilitators identified a marked underutilisation of bedside alert signs (4%), prompting creation of a redesigned bedside poster with a greater focus on sensory aid functionality.

Results

60% of posters were utilised 10 days after introduction, with an increase from 4% to 36% in recording of known sensory impairment being observed. 100% and 25% of inpatients with correctly functioning hearing aids and spectacles were documented respectively. 100% of patients admitted through frailty intervention streams were assessed for sensory loss, compared to 0% admitted via the unselected medical take.

Conclusions

Improved bedside alert posters provided initial evidence as a sustainable improvement in supporting inpatients with sensory impairment. Incorporating positive lessons from frailty team practice will assist in developing future education sessions, highlighting intended sign usage and transferrable sensory assessment methods for involved healthcare teams.

References

1. Hearing Matters. Action on Hearing Loss. 2015. Available at: https://shorturl.at/tBEST [Accessed: 23 Nov 2023].

2. Healthy Ageing Evidence Review. 2011. Age UK, N.D. Available at: https://shorturl.at/fqAOW [Accessed: 11 Nov 2023].

3. Emond et al., 2015. The current health of the signing Deaf community in the UK compared with the general population: a cross sectional study. BMJ Open 2015.

4. Vos, T et al., 2015. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet. Vol. 386 (9995) pp. 743–800.

5. Prevalence estimates provided by Professor A C Davis, using prevalence from Davis (1995) Hearing in Adults, updated with ONS (2014) National Population Projections. Available at: http://www.ons.gov.uk/ons/rel/npp/national-population-projections/2014-… [Accessed: 11 Nov 2023].

Introduction

The concept of “polypharmacy” is a well recognised phenomenon, forming a keystone of any comprehensive geriatric assessment. We considered whether a similar concept could be applied to the number of outpatient clinics that patients may attend - a concept we have coined “polyclinic”. We recognise that older populations may have a greater number of comorbidities and, as a result, have more healthcare professionals inputting into their care. Similar to the potential detrimental effects of multiple medications, we were interested to explore if a similar detrimental effect may apply to patients attending multiple clinics. We also attempted to consider environmental impacts. We approached this in both a quantitative and qualitative manner.

Method

A cohort was selected from all admissions to a subacute Geriatrics ward at University Hospital of Wales during the month of April 2023. National records were used to review the last decade of clinic attendances. For interviews every 4th patient was contacted

Results

66 patients (75% female) were identified with 3 exclusions. The average number of clinics attended was 18.4 with 0.36 new diagnoses being made per clinic and 0.69 interventions per attendance. Geriatric clinic attendance yielded both a higher average number of diagnoses and interventions (0.93 and 1.4 respectively). Patient feedback was limited to 8 patients and 7 next of kin. Feedback regarding ‘worthwhileness’ was very positive with ratings >8/10. Feelings about possible cutting back on clinics or virtual clinic attendance were mixed with concerns regarding suitability and access to technology

Conclusions 

We identified several limitations to this pilot project,  however, overall feedback gained from patients and next of kin regarding clinic attendance was positive.

This study does not have the scope to suggest that attending multiple clinics are detrimental but aims to raise the concept of “polyclinics” that may be overlooked, particularly in a co-morbid population. We have also considered potential patient impact to multiple attendance and concerns regarding possible changes to traditional face to face clinics. With a climate crisis upon us we also draw attention to environmental impacts for consideration.

Background 

Deconditioning in the acute setting is associated with adverse outcomes, that cannot always be mitigated by increasingly stretched MDT workforce. We partnered with the Saints Foundation (SF), to test the feasibility and acceptability of a non-clinical Exercise Practitioner (EP) to work alongside therapies to promote physical activity (PA) of hospitalised older people. 

Methods 

Charity funded joint appointment of an NVQ3 EP with Postural stability Instructor (PSI) qualifications delivered quality education and rehabilitation programmes to hospitalised older patients. These took place in both one to one and gym-based group settings whilst working with the SF team to improve access to community-based exercise programmes. 

Results 

Between Sept 2022 and May 2023, the EP assessed 169 patients, mean age 86 yrs; male (62%), admitted after a fall. 105 patients (62%) underwent one to one rehabilitation consisting of falls education and individual exercise plans, 64 patients (38%) underwent gym-based rehabilitation, where strengthening and balance exercises were conducted in groups to improve overall function and increase confidence in functional ability. No adverse safety incidents were reported and a high level of satisfaction after interaction with the EP was conveyed. Initial focus was on patient feedback and satisfaction to ensure input of an EP was well received and accepted. 

Conclusion 

Intervention by a non-clinical EP to improve the PA of hospitalised older people is acceptable, feasible, appears to be safe and is associated with increased patient satisfaction. By capitalising on SF expertise, we provided a clinical standard on exercise for older adults and built a strong relationship between our workforce to bridge community and acute services. Next steps are to increase the scope of interventions, evaluate quality of life pre and post hospitalisation, capture trust level metrics including length of stay, readmission rates and discharge destination to further evaluate the impact on service users.