CQ - Patient Centredness

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. 

Objective

To conduct a QIP to ensure that >80% of DAU patients’ vision was assessed via the VAT as per National Audit of Falls Prevention Guidance.

Background

Patients with visual impairment are twice as likely to fall than those without. The NAIF 2015 report identified <50% of elderly patients had their vision assessed in hospital; also evident at Southend Hospital.

Methods

Data collection from 56 patients over 8 weeks following weekly interventions helped us analyse their impact on VAT use. Control data (week 1) was pre-intervention.

Intervention

Six interventions were applied over 7 weeks: teaching to nurses, HCAs and doctors about VAT; email to Geriatrics team; reminder email to DAU nursing team and a feedback questionnaire.

Results and Discussion

Mean age was 82 and 38% of patients attending DAU had an ophthalmic history. Pre-intervention (week 1) identified 0% VAT use. In week 2, there was a 75% increase in VAT use after teaching nursing and HCA staff. In week 3, there was only 12.5% VAT use after the poster intervention. In week 4, there was a 25% uptake on VAT use with no intervention.

Week 5’s intervention witnessed 100% in VAT use, which remained high in week 6 (85.7%), 7 (100%) and 8 (100%). The final intervention questionnaire highlighted that 100% of staff were (i) previously unaware of VAT, (ii) agreed on its importance in assessment of elderly patients, (iii) found teaching adequate, (iv) thought there was enough awareness on VAT use via the QIP, (v) agreed that an incomplete VAT was due to inability to undertake section 4 and 5.

Conclusion

VAT use identified 3 ophthalmic problems that would have otherwise not been managed. While the QIP did not meet the target of >80% VAT use, it successfully informed DAU staff in proper conduct of VAT in falls patients.

Background & Introduction

In response to the recent publication of the new British Geriatrics Society undergraduate medical curriculum (1), the medical education department at Glasgow Royal Infirmary created a session focussing on frailty for undergraduate medical students. The aim of the session was to introduce the concept to students by exploring and expanding on their experiences of frailty on placement. 

Methods - The session 

We used a pedagogical approach in a short, 90 minute session for small groups of students. The session was split into three activities; the first activity was a case of an older adult presenting acutely with urosepsis. The session dealt with acute treatment for frail patients including polypharmacy, collateral history taking, and consideration of patients wishes and advanced directives. The second activity presented the students with three patients with differing manifestations of frailty; students  were then asked to discuss the concept of ‘the dying process’, and how they would need to support each patient in differing ways. Finally, students were given a ‘frailty suit’ which included “visual impairment glasses” and “reduced dexterity gloves” then asked to complete several activities of daily living. This light hearted activity allowed students to experience then reflect upon the effects of frailty.

Results

The session was delivered to 25 students, of which 16 provided feedback.  Over 85% of students stated that the session was extremely relevant and well delivered on a Lirkart scale; comments included “...we don’t get taught about it enough in medicine”.  Results highlight that students recognise the utility of frailty focussed sessions in medical education.

Conclusions

We show that students are aware of the gap in frailty curriculum and an interactive discussion focussed session is one way to enhance their understanding of frailty. We present details of the session, and further iterations of the project we hope to introduce during the upcoming academic year. 

References

1. Grace M E Pearson et al, Age and Ageing, 2023, Volume 52, 1-8  

Background:

Nutrition is one of the cornerstones of healthy aging. As we age there are many changes in our bodies, including decreased appetite and poor dentition, that contribute to increasing malnutrition. The MUST (Malnutrition Universal Screening Tool) score is a quick and effective tool to assess this.

Aim:

In this project, we aimed to review MUST score and food chart completion on the frailty wards at EDGH to attempt to improve the nutrition of elderly patients.

Methods:

The charts of 75 patients were reviewed over a period of one month. Following this, a training program for all the nursing staff was put in place. The initial results were discussed and the importance of nutrition in the elderly was highlighted. The staff were shown how to fill in the MUST score and follow management guidelines. Also, a reminder was set up on Nervecentre (electronic patient record) for all staff.

Results:

Of the initial 75 patients;

1 – a MUST score was completed for only 64% on admission.

2 – 41.3% of patients were eating 50% or less of their meals.

3 – In only 27% the reasons why they were not eating were documented.

In the second cycle, 80 patients were included and the results were markedly improved.

1 – The percentage of MUST score completion on admission increased to 91.3%.

2 – Management guidelines were followed in 92.5% of the cases.

3 – 18.8% with a MUST score of two or more, were referred to dietitians at an early stage.

Conclusion:

- Our quality improvement project significantly increased MUST score completion and prompted action at an early stage. 

- The next step is to improve the documentation of patient’s food charts and encourage staff to look for and document the reasons why patients are not eating.

Introduction -The use of anti-psychotics is higher in older people than their younger adult counterparts due to high prevalence of dementia/delirium. Anti-psychotic drugs cause side effects which include cardio vascular, metabolic, extra pyramidal and high risk of falls. So, we set out to do a QIP on antipsychotic medication prescription on our Geriatric wards and compared it with NICE guidelines.

Method- We had 2 approaches to use. Firstly, we prepared a check list for anti-psychotic medication monitoring according to NICE guidelines 2021 and we applied this retrospectively to 17 patients who had been initiated on anti-psychotics within last 12 months, the aim being to compare our practice with best practice. Secondly, we prepared a questionnaire for doctors to assess their knowledge about antipsychotic NICE guidelines and we distributed it to 14 junior doctors in RGH.

Results- • Main Indication for prescribing antipsychotics was Behavioural and psychological symptoms of dementia (BPSD) - 94% of the time • Risperidone was the most commonly prescribed (64%) antipsychotic for our patients • 83% of them had non pharmacological methods tried before considering antipsychotic medications. • 82% had their baseline ECGs checked • 35% had their lipids checked and 47% had their HbA1c checked • 52% of the doctors were aware about NICE guidelines on prescribing anti-psychotic medications • 70% of the doctors had knowledge about the side effects.

Conclusions- Our study showed the most commonly used antipsychotic drug was risperidone. We were good at documenting the indication, trying non pharmacological methods and discussing side effects with patients/family. Hba1c, lipids and prolactin were not often checked, showing room to develop best practice. We therefore are in the process of finalising a sticker so that we can follow the guidance set by NICE for prescription of antipsychotics. To improve knowledge of antipsychotics in doctors, we have presented the findings and aim to put up posters on all medical wards and to teach at our local level during doctor change overs

Introduction

Weight loss is common during acute hospital admissions, and can be devastating to the older patient where weight loss is associated with an increase in mortality over a 12 month period. Patients who lack the ability to communicate their food preferences are at risk of receiving food they do not like, especially as food orders are often taken when family/carers are not present.

Methods

While working on a Department of Medicine for Older People and Stroke (DMOPS) ward, we worked with the Multidisciplinary team (MDT) with the aim of reducing weight loss. We implemented two interventions. The first being ‘MUST Mondays’, where patients were weighed and had a Malnutrition universal screening tool (MUST) completed on admission to the ward, and then weekly. We also implemented A3 Laminated menus - where patients and their families/carers were given food choices for the week in advance, and could use a marker to identify foods they did/did not like. These were then displayed above the bedspace. All patients were over the age of 65. We excluded patients who were actively dying, patients who were aiming for weight loss (Such as in fluid overload) and patients who were admitted for fewer than 8 days.

Results

Prior to putting the interventions in place, we audited 23 patients admitted over a 3 month period. 70% of patients lost weight over the course of their admission, and 48% had MUST assessments completed weekly. We re-audited 5 months after the interventions were implemented, we audited 20 patients over a 5 month period and found 55% lost weight over the course of their admission, and 80% had weekly MUST assessments.

Conclusion

Working as an MDT to put in place small interventions can have a meaningful impact on reducing weight loss in older patients during acute hospital admission.

Introduction: Virtual frailty wards, where patients are treated at home who otherwise would be in an acute hospital, are a model of care being promoted within the NHS in the UK, with the aim to ‘provide an alternative to admission and/or early discharge’. The evidence base for this model of care is limited and the ideal set up has not been defined. The aim is to describe the implementation and delivery of a virtual frailty ward serving a rural community.

Methods: Creating a 7 day a week frailty virtual ward integrated across primary and secondary care. A multidisciplinary team (MDT) focus was adopted utilising existing staffing from partner organisations. Data was collected over a 12 month period. A comprehensive geriatric assessment (CGA) approach was adopted. Daily patient reviews were completed and treatments adjusted with findings. On discharge from the ward patient, carer and staff satisfaction feedback was gathered.

Results: 466 patients managed on the ward, with an average length of stay of 3.7 days. 1724 inpatient bed days saved. Minimum save to the acute trust £862, 000. Average 37% direct hospital avoidance community step-up patients. Average 63% early discharge from hospital step-down patients. 98% positive feedback.

Discussion: Close collaboration across healthcare services and development of trust are key to success of a virtual frailty ward. Impact was clear over a 12 month period with 1724 acute bed days saved. Patient and carer satisfaction was high. MDT attendance remained consistent, with positive feedback from across sectors of the hidden value of the shared learning and education. Actual savings in relation to wider effects are outside of this scope of this study e.g. deconditioning, mortality, but positive outcomes from CGA have been widely published. Further work is required to become more proactive in hospital avoidance and increasing numbers of step up patients.

Rationale: The Frailty Intervention Team (FIT) is a multidisciplinary team that provides a service to community based frail adults. This particular service is novel in the sense that it is a hospital based out-patient service as opposed to a frailty at the front door or a community based service, and has access to rapid diagnostic and intervention services. As this is a novel service a qualitative study was undertaken to assess patient satisfaction and guide the direction and development of future quality improvements initiatives.

Objective: To evaluate the satisfaction of service users with the implementation of an out - patient Frailty Intervention Team in a Model 2 Hospital setting.

Implementation: A mixed methods study was carried out in the form of a patient satisfaction survey which included quantitative questions as well as Likert Scale closed ended questions and open ended questions. This qualitative data was analysed by collating common words, creating word clouds to organize the ideas and suggestions made.

Outcome: Of the 150 surveys disseminated there was a 46.7% response rate. 66% of responders rated the services ability to meet their expectations as “excellent”. The main qualitative outcome of the survey was that service users felt they needed ‘a report sent to myself so I can remember’. Thus the Patient Action Plan Leaflet was developed where each discipline writes a summary of the intervention and advice provided during their assessment. A copy of this is then provided to the patient after each appointment.

Conclusion: This mixed method study resulted in service user feedback guiding a positive change to the provision of the service for the direct benefit of service users. Future research will aim to evaluate the effect of the Patient Action Plan Leaflet.

Background:

Good nutrition and hydration are essential to patient’s health and wellbeing. Reduced nutrition leads to increased hospital admissions, re-admissions, longer length of recovery, poor wound healing and sarcopenia. Introduction: In hospital inpatients, especially when frail or vulnerable, the ward’s duty is to ensure that appropriate pathways exist to support their nutritional status and identify those who need additional support, additionally making sure patients have access to food and drink. Our ward wasn’t compliant with hospital standards. Additionally, patients experienced social isolation at mealtimes which negatively impacted on patient mood and calories consumed.

Methods:

Over 4 weeks, utilizing existing ward staff, we implemented a lunch club. This involved facilitating a communal lunch on the ward. Our main outcome measures were calorie and protein consumption. 40 data sets were obtained from what was recorded on the patient’s food chart and cross referencing it with the dietary information provided by the health board catering department. We also gathered data on WAASP score compliance comparing wards who had regular lunch clubs to those who did not.

Results

Attending lunch club resulted in a 68% increase in calorie consumption. In addition to this protein intake was increased by 73%. Wards where there was a DSW 97% of patients were screened for malnutrition, compared to only 61% on the wards without a DSW. Furthermore, on the wards without a DSW only 30% of patients were weighed once a week compared to 100% of those on a ward with a DSW. Not only did we see an objective increase in the calories consumed, patient enjoyment of mealtimes was increased as well as their time socializing during their in-patient stay

Conclusion

Lunch club increased calorie consumption, but it’s not sustainable without appropriate staffing. Comparing wards with and without DSW, there are clear discrepancies managing malnutrition.