CQ - Patient Centredness

Introduction: Modifiable risk factors are an important part of secondary prevention of ischaemic stroke. Many of these are modifiable lifestyle choices. We identified a lack of provision of written information to patients on the stroke ward regarding modifiable lifestyle risk factors, and undertook a quality improvement project which aimed to improve provision of information - both written and verbal - via a "Stroke Passport" document to help patient understanding.

Method: Data was collected from inpatients admitted with ischaemic stroke in the stroke ward in Prince Charles Hospital (District General Hospital), Merthyr Tydfil. A self-rated questionnaire was used to collect data on patients' perceived understanding about risk factors, and the quality of verbal and written information received during their admission pre and post introduction of a “stroke passport” document, containing written information on modifiable risk factors for stroke. Patients with delirium or unable to understand were excluded. Patients were verbally consented and helped with understanding the questionnaire by a stroke specialist nurse.

Results: Baseline data was collected from 21 patients. After introduction of the “Stroke Passport” document, data was collected from 21 different patients. Patients' perceived knowledge improved from 67% to 95% following the introduction of the stroke passport, patients’ perception of receiving verbal information from staff went from 62% to 95% and patients' perception of receiving written information increased from 0% to 100%.

Conclusion: This quality improvement project demonstrated improvements in patients’ perceived knowledge of modifiable risk factors, and in perceived quality of patient education. We suggest that a “stroke passport” document to help guide patients through their stroke journey is of benefit to patient's understanding of risk factors, and standardising the provision of written patient information. Further cycles aim to improve the educational quality of the material by assessing improvement in patient knowledge.

Introduction                                                                                                                                                                        High number of clinically optimised patients in a DGH were having daily clinical input. RAAC clinical incident resulted in movement of clinically optimised patients from the district general hospital to a community hospital increasing the community bed base from 32 to 72. This gave the opportunity to review how these patients were managed.             

Method                                                                                                                                                                                    It was recognised that a daily medical ward round for clinically optimised patients was neither necessary or optimal and potentially perpetuated the impression that patients required in hospital care. National guidance supports delegation of daily review to other members of the Multidisciplinary Team. All clinically optimised were planned to be seen once a week on a medical ward round. All patients were discussed on the daily multidisciplinary board round and if needed were changed on the board to not clinically optimised which prompted review. Nurses could also ask for review outside of the board round.                                                                                                                                                                             

Results                                                                                                                                                                            During four weeks period one third ( 24/72 ) of patients needed review outside of the weekly planned review. Of these 79.2% required only one review. Junior doctors reported that they previously spent 5-15 minutes per day per clinically optimised patient. Therefore time saving of 16-48 hours per week was estimated. Balancing measures of falls, mortality, pressure sores and complaints showed no change in the four months after implementation of the change. Patients, family and staff qualitative feed back was gathered. Stage two of the project offered clinically optimised patients a ' What Matters to Me' meeting with their family utilising the time saved by reduced ward rounds to improve communication, medication review and future care planning.                                                                                            Conclusion                                                                                                                                                                          Data suggested no adverse impact of change in practice. Staff were redeployed to the front door frailty team rather than community hospital to improve access to Comprehensive Geriatric Assessment at admission in the Emergency Department and Acute Frailty Unit.

INTRODUCTION The Cardiff and Vale Parkinson's service is an integrated, multidisciplinary service providing support and input from initial diagnosis to end of life care, undertaking comprehensive, specialist assessments for patients. Traditional care models have focused on physical disease, with neuropsychiatric symptoms often requiring input from other (e.g. Mental Health) teams to manage even the less- complex symptoms of dementia. Our service aims to manage both physical and neuropsychiatric symptoms via non-pharmacologic and pharmacologic means.

METHODOLOGY From our total clinic population, a cohort of 425 people with established idiopathic Parkinson's who were subsequently diagnosed with Parkinson's dementia (PDD)in the decade 2013-2023 was identified. From this cohort we assessed a sample of 50 people (56% male, 44% female, mean age 75 years) for advanced demographics, disease duration, presenting dementia features and the diagnostic method.

RESULT From our database of 3668 clinic patients, 425 people with PDD were identified. 76% people with PDD (n=325) were prescribed acetylcholinesterase inhibitors. Subgroup analysis (n=50) demonstrated that cognition was assessed by a range of tests: ACE (60%), MoCA (22%), clinical opinion alone (16%) or RUDAS (2%). Neuroimaging was undertaken in 50% patients, predominantly to exclude other pathologies. The mean time from PD diagnosis to PDD diagnosis was 6.5 years, and survival from PDD was a mean of 3 years.

CONCLUSION When cognitive impairment or dementia develops in Parkinson's, care provision by the same team ensures continuity for People with Parkinson's (PwP) and their families or carers. PwP live for an average of 3 years post-dementia diagnosis and so joint training in both 'traditional' Parkinson's care and diagnosis and management of dementia allows for a truly holistic approach in managing the complex interplay between motor, non-motor and neuropsychiatric features that manifests later in this condition.

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.