CQ - Patient Centredness

Introduction: Treatment Escalation Plans (TEPs) are helpful tools that reduce un-necessary treatment burden, improve patient experience and follow the principles of realistic medicine. This is relevant in orthopaedics where a high percentage of the patients are frail, co-morbid, and would benefit from clear and realistic care plans. We aim to improve TEP completion to >50% of orthopaedic patients, over the age of 65yrs old, in three trauma wards at the Royal Infirmary of Edinburgh by August 2023.

Methods: We sampled three patient notes on each ward twice weekly from May – August 2023, noting whether TEPs were present, if it was consultant endorsed or provisional, and what key sections were completed (resuscitation, treatment goals and communication). To be included, the patient had to ≥65 and under orthopaedics. Process mapping demonstrated 2 key targets- admission clerk-in and registrar review. PDSA 1 involved creating a prompt for documenting TEPs on FY1 clerk-in which was added to the admission proforma folder and displayed as posters. PDSA 2 was a teaching session designed for orthopaedic registrars and other team members about TEP conversations.

Results: Pre-intervention data, demonstrated a median of 28% of orthopaedic patients ≥65yo have a TEP. Of the completed TEPs: 88% solely consisted of a resuscitation decision; 33% had treatment goals, 33% communication; and 0% of TEPs were endorsed. After PDSA 2; median TEP completion increased to 33%. Of the completed TEPs; none had only a resus decision, 100% have treatment goals; 100% communication, and 83% are endorsed.

Conclusions: Our studies have demonstrated that education and proforma changes have increased TEP documentation rate, although not to our projected target. However importantly, the percentage of TEPs that contain goals, document communication and consultant endorsement has improved significantly. This project is ongoing with with planned further PDSA cycles.

Introduction:

Atrial Fibrillation (AF) causes 15% of ischaemic strokes. The National Clinical Guideline for Stroke recommends at least 24 hours of cardiac monitoring and a longer duration if cardio-embolic stroke is suspected. The British Heart Rhythm Society suggests up to 72 hours of cardiac monitoring. Currently, there is little data on the use of telemetry in detecting AF in acute strokes.

Aims:

Our study aims to evaluate the detection rate of new onset AF in acute stroke with telemetry and to determine if there was any correlation between the duration of telemetry and the detection rate of AF.

Methods:

All patients with ischaemic stroke who were admitted to stroke ward over a 3-month period were retrospectively analysed. Exclusion criteria were patients who were known to have AF, had new AF on admission electrocardiogram, patients receiving palliative care, patients who were discharged home early without having a telemetry and patients with missing records.

Results:

61 patients met the inclusion criteria and 5 (8.2%) had AF on telemetry. Two patients had AF on day 1, one on day 2 and two on day 3. All of these patients were anticoagulated. The duration of telemetry ranged between 1- 19 days however no AF was detected beyond the third day of this study.

Conclusions:

AF was detected in 8% of patients with ischaemic stroke within the first 72 hours of admission. Among the patients in whom AF was detected, 5% were detected between 24 hours and 72 hours of admission. Studies (EMBRACE and CRYSTAL trials) have shown that prolonged cardiac monitoring (30 days and 6 months to a year respectively) resulted in higher detection rates of AF. This study suggests that patients with ischaemic stroke should be monitored for at least 72 hours due to a higher detection rate of AF.

Background End-of-life (EOL) care aims to anticipate, prevent and treat symptoms experienced by the dying patient. An EOL care strategy described by King’s Health Partners (KHP) outlines the ‘ICARE’ framework, created from the five priorities for the dying patient, giving generalist hospital teams a memorable prompt to consider holistic needs of patients. We aim to reconcile performance of Acute Medical Unit (AMU) in providing EOL care, against KHP's framework, to reduce patient suffering and improve care. Methods A prospective review was performed of all AMU deaths from March-September 2021, reviewing resuscitation status and EOL medications. Sudden deaths for full resuscitation were excluded. Following review, teaching to AMU was delivered and a wall poster of the ‘ICARE’ framework was displayed. A second prospective cycle was performed reviewing deaths from March-September 2022. Results 50 deaths were recorded in cycle one. 21% (12/58) of dying patients were not prescribed EOL medications. Medication omission for 50% (6/12) of patients were due to lack of recognition of EOL. Other reasons included no consultant review, undecided resuscitation status and a missing prescription. In cycle two, 11% of dying patients (6/48 patients) were not prescribed EOL medications, all of which were due to lack of recognition of EOL. 12 deaths had EOL medications prescribed but had an inappropriate resuscitation status. Conclusion The second cycle showed a 50% reduction in deaths with EOL medication omissions, when compared to the first cycle. Reasons for medication omissions were less varied in cycle two, highlighting reduction in avoidable causes. Although not affecting patient care, a notable number of patient records had incorrect resuscitation statuses. Overall, improvement in delivery of EOL care within AMU can be seen. Future considerations involve emphasis on keeping electronic patient record up to date to avoid errors and continual provision of education to new and rolling staff.

Introduction Factors contributing to frailty result in increased hospitalisations, with 5- 10% of patients attending Accident and Emergency department living with frailty, and 30% of those patients admitted to acute medical units (Conroy, 2013). Hospital admissions result in functional decline and deconditioning (Get It Right First Time, 2021). The number of people in the UK over the age of 85 is set to double in the next 20 years and treble in the next 30 (Office of National Statistics, 2013). Their needs are best met in the community with a multi-disciplinary approach. Method Patients, residing in Benfleet and Leigh-on-sea, discharged from Geriatric wards at Southend Hospital were identified during ward MDT meetings. Inclusion criteria: • Recurrent admissions • Prolonged hospital stay • Clinical Frailty Score > 5 • Social support Using this criteria, 216 patients were included. 7 day readmission and 30 day readmission data was collected and compared to readmission rate prior to intervention. Intervention On discharge patients were linked with Frailty Nurses within their Primary Care Network and were reviewed within 48- 72 hours of discharge. Community support was provided via MDT, with involvement from consultant geriatrician. Concerns that could result in readmission were highlighted during these meeting, with patients being seen in Day Assessment Unit for review of sub-acute frailty syndrome if appropriate. Results Following intervention of utilising community MDT there was a reduction in rate of readmission. 9 patients (4.1%) were readmitted within 7 days of discharge and 14 patients (6.4%) were readmitted within 30 days, in comparison to 7.6% and 19.3%, respectively, prior to commencement of MDT. Conclusion This concludes that utilising community MDT with review following discharge has positive impact in reducing readmission rates. Highlighting potential risks of readmissions allows the MDT to address issues within the community and use bridging services appropriately.

Introduction

Advance care planning is a cornerstone of holistic care in patients with dementia. I conducted a quality improvement project (QIP) in Musgrave Park Hospital on the Orthogeriatrics Ward. The QIP focused on advance care planning in patients with moderate to advanced dementia.

Method

The target cohort was post-operative fracture patients with a formal diagnosis of dementia. Patients with moderate to advanced dementia were identified using the clinical frailty scale. Once a patient was identified, I ascertained whether the patient had capacity. If the patient was not deemed to have capacity, questions were deferred to the next of kin (NOK). The patient or NOK was asked ‘if an ACP was in place?’ and if an ACP was not in place, they were the asked ‘if they were aware of what an ACP is?’.

Results

I collected data between 1^st March 2023 and 1^st April 2023. Eighteen patients were identified. No patients were deemed to have capacity and therefore, all questions were deferred to their NOK. No patients had an ACP in place and only one NOK was aware of what an ACP is.

Conclusion

The data collected showed that no patients had an ACP in place and that there was a significant lack of education regarding what an ACP is. This lack of understanding concerning what an ACP entails may be preventing ACPs from being completed in the community. I designed a leaflet which summarised the key aspects of advance care planning. These leaflets will be handed out to patients or their NOKs. I will follow up on these patients to see if education has led to an ACP being put in place.

Introduction

AFU aims to provide Comprehensive Geriatric Assessment to frail, older service users.  A key component is Medication Review.

Patients living with frailty are more susceptible to medication side-effects and are often on Falls Risk Increasing Drugs (FRIDs¹) and medications with Anticholinergic Burden (ACB²) effects, which can cause falls/confusion/delirium/hallucinations. Aiming to reduce inappropriate polypharmacy, ACB and FRIDs scores, and optimise bone health is therefore essential.

Data highlighted only 17% of patients received Medication Review by a Pharmacist, which needed addressed without additional resources.

Method 

Medication Review usually involves a Pharmacist working alone and can be a lengthy process. We suggested a team approach with preparation and clinical details brought to a focused meeting with decisions made collectively.

After identifying key stakeholders, we introduced a focused Medication Review meeting twice weekly. 

Aims of review: reduce ACB and FRIDs scores, discontinue medications no longer indicated, improve bone health with a patient-centred approach throughout.

We produced a data collection form for audit purposes, and agreed how to communicate suggested changes to patients and other staff. 

Results

109 patients audited from October 2022-March 2023.

Medication Reviews increased from 17%-69%.

Improvements noted: average number of medications reduced from 9.5-9.0 (reduction diminished by addition of bone optimising medications³), number of patients with ACB ≥3 reduced from 32-11, average ACB score reduced from 1.9-0.9 and FRIDs score from 5.5-3.4.

ScHARR⁴ potential cost avoidance for 557 interventions was £37,501 - £86,218 with an average of 5 interventions/patient.

Conclusion 

A focused multidisciplinary Medication Review led to a reduced ACB and FRIDs score, with a potential saving from interventions. It also increased the number of patients receiving a Medication Review.

This innovative way of providing Medication Review makes best use of our time and skills, encourages education, and promotes conversations with patients/families about medications to see what matters to them.

References

1.  FRIDs (Falls Risk Increasing Drugs)

Northern Ireland Medicines Optimisation in Older People (MOOP)

2.  ACB Calculator

Available at: https://www.acbcalc.com/

3.  FRAX® Fracture Risk Assessment Tool

Available at: Frax.shef.ac.uk. (2023)

4.  ScHARR Potential Cost Avoidance

Karnon, J.; McIntosh, A.; Dean, J. et al. Modelling the expected net benefits of interventions to reduce the burden of medication errors. J. Health Serv. Res. Policy 2008, 13, 85–91.

Introduction

Using a patient centred, valued based health care approach to reshape the acute frailty unit with the University Hospital of Wales. Our multi-disciplinary team provide our patients with a compressive geriatric assessment. The goal is to ensure our patients are treated in a timely, thorough manner to avoid deconditioning and hospital induced harm. We want our unit to be guided by the needs of our patient population.

Methods

A redesign of the service structure within the acute frailty unit was undertaken as a result a patient survey taken in 2021. The aim was to focus on concerns that patients had highlighted within their feedback; noting particular challenges with length of time spent within the accident and emergency department, access to analgesia and continence needs. We were able to note these concerns and work on redesigning our care model to focus on meeting these needs.

Results

Following these changes, we undertook focused interviews with patients. They speak positivity about their stay within our acute frailty unit; noting they feel listened to about their goals, they are kept up to date with their treatment plans and that the staff genuinely care. They continue to be concerned with regards to access to emergency ambulances and length of stay within the accident and emergency department.

Conclusion

Further significant changes have been made to the service structure following additional patient feedback. Our number of beds within the acute footprint of the hospital have been increased from 12 to 19. We hope that this, alongside a streamlining of the complete admissions process within the University Hospital of Wales, will allow us to continue to provide patient centred, valued based health care to our patient population.

Introduction

The Cardiff and Vale Memory Team is comprised of a range of healthcare professionals who provide direct and indirect contact to coordinate the care of dementia patients. Memory link workers (MLWs) are a single point of contact for patients; they contact patient’s post-diagnosis and at 6-month intervals. Clinical Nurse Specialists (CNSs) assist patients with medical aspects of their care, including diagnostic home assessments with the support of the medical team. This evaluation aimed to establish the impact of these roles on people living with dementia and their carers.

Methods

This study is a retrospective service evaluation of 200 patients, who contacted the MLWs and CNSs between early April and mid-May (289 contacts). PARIS, Welsh Clinical Portal and written notes were used to collate information on patient demographics and each contact.

Results

The majority of patients were female (70%), the median age was 83 and Alzheimer’s was the predominant diagnosis. The greatest need identified in both MLW and CNS contacts was social care provision (39%). MLWs predominantly addressed wellbeing (n=55), CNSs had discussions surrounding medication (n=39) and physical health (n=44). The most common subjective outcome in the MLW group, was improvement in quality of life (75%); in the CNS cohort it was addressing acute medical problems (37%). Overall, the contacts were divided as follows, quality of life (50%), admission prevention (24%) and acute medical (24%).

Conclusion

The service is proactive and addresses a variety of needs; it has the potential to improve patients' quality of life and prevent admission. Both professionals were able to identify deteriorating patients and increased carer burden; additionally, patients were able to receive a diagnosis in a home setting. The service could be improved with more frequent contact, streamlined links with social services and increased liaison with mental health services to improve speed of access.

Introduction:

Urinary incontinence, one of the original geriatric giants, is frequently overlooked despite its potential for reversibility and profound impact on older adults. The purpose of this audit was to evaluate the prevalence of continence and utilisation of incontinence wear among inpatients in a rehabilitation facility.

Methods:

Continence care quality in a medical gerontology ward was evaluated using the Royal College of Physicians (RCP) National Audit of Continence Care (NACC) standard. A prospective audit was conducted over a five-day period, documenting continence wear and urinary continence. Two interventions were implemented before re-auditing: incorporating continence as a teaching topic in the non-consultant hospital doctor (NCHD) teaching schedule and adapting the multi-disciplinary team (MDT) proforma to include patient-specific continence records. A snapshot re-audit was then conducted to assess any improvements resulting from these interventions.

Results:

The initial audit included 31 patients, with 26 (83.9%) wearing incontinence wear, of whom 21 (80.8%) opted for it voluntarily. Urinary incontinence was documented in 13 patients (41.9%).

In the re-audit, 40 patients were included, with 27 (67.5%) wearing incontinence wear, of whom 19 (70%) made the choice. Urinary incontinence was documented in 18 patients (45.7%).

Conclusion:

The re-audit revealed a slight decrease in incontinence wear usage (67.5% compared to the initial rate of 83.9%). Many patients wearing incontinence wear expressed a consistent preference for it in both audit cycles. The prevalence of urinary incontinence remained relatively consistent between the initial audit (41.9%) and the re-audit (45.7%).

The persistent prevalence of urinary incontinence calls for effective strategies to address this issue. Furthermore, the patients' preference for incontinence wear underscores the significance of engaging both the MDT and the patients themselves in future interventions. Future projects should focus on gaining a deeper understanding of patients' perspectives on continence care and evaluating the impact of incontinence on patient outcomes.

Introduction: Across the UK, emergency and assessment units are faced with the challenge of streamlining urgent care services which best meets the requirement of older frail patients.

Method: Patient pathways were mapped using real-time and retrospective data collected from the notes of 30 frail patients over 75 admitted to ED under medicine. Frail patients were identified by the Frailty Intervention Team, and patient demographics were noted. Key touchpoints and the date/times of initial treatment and investigations were documented. Experience questionnaires produced by the Acute Frailty Network were completed to capture the perspectives of 38 frail patients over 75.

Results: Of the 30 patients admitted to ED, 21 (70%) had cognitive impairment and 16 (53.3%) patients had a frailty score (FS)>4. The median time spent in ED/AU for the cohort was 95 hours 31 minutes (approx. four days). The median trolley wait for the cohort was 30 hours 42 minutes (IQR 17hr 42 min-48hr 22 min), 34 hours 22 minutes for patients with cognitive impairment and 28 hours 17 minutes for patients with FS>4, which were significantly longer than the one-hour Silver Book standard. Of the patients admitted during the day, the CGA was performed within 24 hours 9 minutes (IQR 21hr-41 hr) of admission, which does not meet the Silver Book standard of one hour. The median number of night transfers within ED/AU was 1, with 51.5% done at night. Questionnaire results highlighted suboptimal environments, with over 50% of patients feeling indifferent or unhappy during admission.

Conclusion: Both quantitative and qualitative data demonstrated challenging patient journeys in ED/AU. The crowded and busy environment of ED/AU needs to be more conducive to addressing the complex needs of frail individuals. Establishing an acute frailty unit within ED would provide rapid patient-centred care for frail patients.