CQ - Patient Centredness

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.

Introduction

During 2022, non-femoral fractures that didn’t require operative management had 30 days median inpatient length of stay (LOS) at SBUHB. Femoral fracture patients >65 years had LOS 36 days (GIRFT average 19 days), with 720 admissions. High local incidence is believed to be contributed by historical failures to identify and treat non-femoral fragility fractures. A new service was created from a collective effort to do better for our patients and prevent avoidable harm by breaking down barriers between services and promoting effective collaborative working.

Methods

A collaboration between the following key services was formed :- 1. Older Persons Assessment Service (OPAS) -identify fragility fractures presenting to ED 2. Orthogeriatrics -identify suitable femoral fracture patients 3. Physiotherapy -early assessment and transfer to reablement into the community. 4. Virtual Wards –ongoing CGA and reablement in the community Additional resource was secured to provide short-term bridging of care and community therapy input. Data was prospectively collected and included demographics, site of fracture, referrer and LOS.

Results

From March 2023, the service identified 457 patients, 312(68.7%) Female, median age 86 years. 157(34.6%) patients had a femoral fracture and 300(65.4%) were non-femoral fragility fractures, majority identified by OPAS, with 206(68.7%) being discharged same day. Overall, admission was avoided in 207(45.3%) patients and 247(54.6%) had an early discharge/reduced LOS with 3(0.1%) re-admissions avoided. The mean LOS on discharge is 6.6 days with a calculated monthly bed saving of 13.9 days across the service.

Conclusion

Collaborative working has created an early supported discharge pathway. Femoral fracture patients are discharged earlier, some 3 days post-op, with the necessary support to continue reablement at home. Fragility fractures are identified at the front door and offered same-day discharge with ongoing comprehensive geriatric assessment and reablement within the virtual wards with positive feedback from patients and their families.

1. Introduction

Parkinson’s Disease (PD) is a complex neurodegenerative disorder which impacts nearly all aspects of quality of life. Given the known challenges and risks of complications with PD, it is crucial to improve management prior to admission for surgery, in particular accurate medication timing and dose. Therefore a quality improvement project on this subject was initiated.

2. Method

A retrospective analysis was conducted of Surgical attendances to Worthing hospital with the aim to identify patients with Parkinson’s disease (PD) admitted under their care. Each patient’s hospital records were manually screened using Evolve Live software and WellSky EPMA to extract the information pertaining to PD medications for the audit. Statistical analysis was conducted using Microsoft Excel. The cycle was repeated following interventions of posters and education of surgical teams.

3. Results

In both cycles there were patients attending for elective surgery or admitted into hospital. The following is regarding patients who were admitted to hospital and were on PD medications. For the first cycle, 27 admissions were identified and 20 in the second cycle. In the first cycle, 5/27 (18.5%) had their medications accurately documented, which improved to 9/20 (45%) in the second cycle. First cycle, 16/27 (59%) patients had their medications prescribed correctly, which was similar to 12/20 (60%) patients in the second. 17/27 (62.7%) patients missed doses in the 1st cycle, and 9/20 (45%) patients in the 2nd cycle.

4. Conclusion(s)

From the first cycle, it was identified that PD in patients was not recognised as promptly as it should. It was reflected in the high proportion of incorrect prescribing and issues due to delay in medications. In the second cycle, following our interventions, there was improved awareness of PD with fewer prescribing issues and complications during admission.

Introduction
Non motor symptoms (NMS) management in Parkinson disease is crucial part of the comprehensive management and have significant impact on the care and the quality of life. However, there are limitations in assessing non motor symptoms given the complexity of the symptoms , time constraint in the clinic setting and major emphasis being the motor symptoms.

Objective
To improve the assessment of non-motor symptoms in movement disorder clinics for the comprehensive and personalised management of patients with Parkinson disease. Service Development PD non-motor symptoms Questionnaire was introduced to the movement disorder clinics. Patients attended were asked to fill the questions in advance just before the clinic time or the questions being sent out in the post alongside the clinic appointment letter.

Results
Data collected from the movement disorder clinics before and after the intervention. Twenty unselected patients from before the intervention and twenty after the intervention were reviewed. Data showed that non motor symptoms such as falls, urinary symptoms , sleep and memory were well acknowledged before the intervention. However , there is improvement in recognition of the other non-motor symptoms after the intervention although there is still room for improvement. Further plan 1. Continue encouragement of using the NMS questionnaire and recognising the non-motor symptoms and early intervention for the comprehensive, personalised management of patients with Parkinson disease and to improve the quality of life. 2. Liaison with the secretaries to send out the NMS questionnaires to follow up patients routinely with clinic appointment letters. 3. Aim to re audit in 6 months’ time. 4. Gather patient feedback on satisfaction of non-motor symptoms recognition and getting addressed with intervention.

Introduction: Frailty is an important consideration in the health and wellbeing of older adults, particularly as it is associated with a risk of falls, and mental health difficulties such as depression. There has been no validation of frailty assessment tools among older adults with Psychiatric disorders. This was a feasibility study exploring the use of the Edmonton frail scale (EFS) among patients with highly complex mental health needs within a Psychiatric Inpatient Setting with a view to develop a service integration process leading to further research.

Methods: 45 participants were recruited from 8 older adult wards across Neuropsychiatry and Medium Secure divisions. EFS assessments were completed every six months by trained members of Multidisciplinary Teams over a 12 month period.

Results: About 118 assessments were administered to approximately 45 patients, regardless of a patient’s length of stay at the hospital during the 12-month period. There was a 55% assessment completion rate. This was largely the result of difficulties in administering the cognitive domain of the EFS (Clock Drawing test) to patients with highly complex mental health needs, as the completion rate was 32%. It was also quite challenging for patients to understand and comply with the assessment instructions in the Functional Performance Domain (Timed Get Up and Go Test). As a result, many assessments in this domain were conducted through covert observation of patients’ movement during the course of the day. 29 of 45 patients had at least moderate level of frailty.

Conclusion: Older adults with psychiatric disorders may benefit from having an adapted assessment of the cognitive and functional domains to promote complete administration of assessments. Prevalence of frailty is high in this setting. Continuous support towards staff engagement and education would be beneficial in promoting EFS use in determining frailty and integrating it into care planning.

Background

NICE (2023) Shared Decisions Making (SDM) Guidelines ensure Health Care professionals work together with a person to reach a decision about care based on their individual preferences, beliefs, and values.

Local Problem

We conducted an Audit across our community services to assess NICE SDM, achieving 71% compliance. Results informed the project problem statement “Clinical Teams are not fully compliant to NICE SDM guidelines therefore a shared decision-making approach is not guaranteed”.

Methods A fishbone diagram was applied to understand why SDM wasn’t routinely occurring in clinical practice. Our aim is to achieve organisation wide adherence to SDM. We propose a multi modal approach to increasing awareness of SDM across the organisation. We used a driver diagram working backwards from the goal, identifying the drivers and determining the project activities. Interventions Due to the enormity of rolling out a pan-organisational programme we decided to use the Frailty NHS@Home virtual ward to test and learn before greater adoption. We firstly processed mapped how the “What Matters to you?” question is embedded into our Comprehensive Geriatric Assessments. A decision support grid for treatment option decision making was created for dehydration or high risk of dehydration within the NHS@Home service, adapted from Marrin et al (2014). Three options are described underpinned by five questions. Feedback from Patient and public involvement ensured the language was appropriate. After the first PDSA cycle, the tool was reviewed by the project team and two further questions were added, “Did you understand the options which were explained to you?” and “What matters most to you as we decide together how best to treat your dehydration?”.

Conclusion

A re audit and colleague survey will reveal increased knowledge and understanding of the SDM concept. We continually seek Feedback from individuals who use our services for their experience of SDM processes.

Introduction: It is well established that older adults with hip fracture benefit from comprehensive geriatric assessment (CGA), but there is less evidence for its use in major trauma. Since 2012 Major Trauma Centres(MTCs) have opened across the UK, with varying access to CGA. We report the requirement and impact of CGA in a MTC in its first year of opening.

Methods: We reviewed all adult patients admitted under the South-East Scotland MTC included in the Scottish Trauma Audit Group (STAG) database from 1st November 2021 – 31st October 2022. We compared: patients under 65y, patients ≥65y who did not undergo CGA, and patients ≥65y who underwent CGA. Outcomes were: review by ED consultant within one hour of presentation, trauma team activation, injury severity score (ISS), CGA within 7 days if CFS≥5, and mortality at 30 days.

Results: 1322 patients were identified: <65y (n=632, median age 48y), ≥65y without CGA (n=397, 77y), and ≥65y with CGA (n=289, 85y). The commonest mechanism of injury in all three groups was fall from standing height (29%, 60%, and 73% respectively). ED consultant review within 1 hour occurred in 37%, 26% and 17% of cases, with trauma team activation occurring in 34%, 20% and 9%. Median ISS were: 10, 10 and 9, and commonest sites of injury in those over 65 were external (e.g. skin), chest and limb. CGA was undertaken within 7 days in 95.1% of those with a documented CFS≥5. Mortality at 30 days was 2.9%, 12% and 8%.

Conclusions: A fifth of patients admitted to our MTC in the first year were older adults with CFS≥5. These patients were undertriaged at several stages despite comparable average ISS across groups. CGA may reduce 30 day mortality. We recommend further research into the benefit of CGA within MTCs.

Introduction

The Rockwood Clinical Frailty Scale (CFS) is a tool that assesses global frailty, validated for use in people aged over 65. It assesses an individual’s functional status to assign a number from 1 (very fit) to 9 (terminally ill). Hull University Teaching Hospitals has integrated mandatory CFS assessment on admission for inpatients aged over 65. This project aimed to improve the accuracy of CFS scoring in an oncology and a geriatric ward by empowering ward nurses to better recognise frailty.

Methods

Phase 1.
Baseline data was collected from admission CFS scores from inpatients on one geriatrics ward and one oncology ward. We then individually reviewed admission CFS scores for the same patients. We recorded concordance if the same score was assigned.

Phase 2.
We surveyed nursing teams on both wards, as they assign the initial CFS score during a patient admission. This revealed unanimous recognition of the pivotal role accurate frailty recognition plays in targeting individualised frailty intervention and called for more staff training in frailty/CFS.  Following this, we introduced a pictographic version of the Rockwood CFS scale to nursing stations where admission documentation takes place and re-assessed CFS score concordance.

Results

A substantial improvement in CFS score concordance was demonstrated within the geriatric ward, from 41% at baseline to 56%. However, only minimal change was observed within the oncology ward remaining static at 11.1% from baseline 8.3%.

Conclusions

We have worked with the two wards to disseminate knowledge and use of the NHS CFS app. Through collaboration with the trust’s frailty leads, the CFS app is now being incorporated into the electronic recording system, encouraging routine use of the app when calculating CFS scores. Once this change is implemented, we will recollect data again.

Introduction

by 2025 over 1 million people will be diagnosed with dementia in the UK. Person-centred care is the best practice for looking after patients with dementia, but this is often not managed well within acute hospital settings. This can result in poor hospital experience and longer than necessary stay. A snapshot of data was taken retrospectively from May 2023 within the ED & AMU at an acute hospital. This showed an average length of stay (LOS) of 5.25 days. A study in 2013, which implemented This Is Me (TIM) documents in hospital saw a reduction in inpatient falls, improved patient experience and in turn LOS reduced.  

Aim: To reduce LOS and improve the patient experience for people with dementia presenting to the hospital following a fall. 

Method

A two-week pilot was implemented in ED & AMU 7 days a week, 8-6pm. Patients were identified through the ED therapy screening process. Paper copies of the TIM were filled in for patients meeting the criteria. Inclusion criteria were admission with a fall and had a dementia diagnosis. LOS data was collected and follow-up data was collected.

Results

Twenty-five patients met the inclusion criteria. Every patient had a TIM document completed within 48 hours. The average LOS was 1.87 days. All patients/relatives reported the TIM was important, and that it improved information transfer. There were several limiting factors including the time involved to complete the TIM, reduced weekend staffing and limited awareness from the multidisciplinary team of the TIM document. 

Conclusion

To conclude, using the TIM Document facilitates a reduction in LOS and an improvement in patient experience. Further recommendations such as launching this project for a longer time frame, using an electronic version of TIM and MDT teaching.