CQ - Patient Centredness

Introduction

People with Parkinson’s disease (PwP) are more likely to be admitted to hospital and have longer lengths of stay than those without Parkinson’s disease (PD). Parkinson’s UK and NICE have proposed standards of care for inpatients with PD, including that PD specialists are alerted when PwP are admitted to hospital. 66% of UK hospitals don’t have an alert system in place, including King’s Mill Hospital (KMH).

Audit

Over a 6 month period, referrals to the PD service in KMH were audited. 128 referrals were made; 5 per week on average. Hospital-wide, around 12 PwP are admitted weekly. Therefore under 50% are referred for specialist input. 64% of patients had been in hospital over 24 hours before referral. 16 patients were referred to the PD service more than once during admission, reflecting ongoing management difficulties.

Intervention

The digital transformation team completed software changes to create an electronic alert when PwP are admitted to hospital. The local system for recording admission details and electronic prescribing, NerveCentre, can now generate an electronic list showing all inpatient PwP. A multi-disciplinary virtual PD ward round was introduced. Using NerveCentre, all PwP can be remotely reviewed and triaged. Proactive, positive interventions from the specialist PD team include: constipation management, osteoporosis screening, speech and language therapist review, cognitive assessment, issuing dysphagia cards, and advance care planning. NerveCentre enables remote medication reviews and audit of prescribing, ensuring that any breaches of the ‘Get It On Time’ campaign are reported via Datix, with relevant learning shared. The virtual ward round provides training opportunities for specialist registrars, junior doctors, and newly appointed PD specialist nurses.

Conclusion

The electronic flag permits more comprehensive, proactive and timely inpatient reviews of PwP. The interventions from this project enable the Trust to meet Parkinson’s UK recommendations and hopefully improves the inpatient experience of PwP.

Background

This project was completed by a team of junior doctors working across two general medical wards at Queen Alexandra Hospital.

Introduction

Due to persistently high bed occupancy, patients are increasingly subject to multiple moves, increasing the risk of missed or delayed communication (Toye C et al, Clin interv aging, 2019, 14, 2223-2237). Importantly, families who receive good communication from staff are more likely to feel satisfied with the care of their loved one (Ersek M et al, J pain symptom manage, 2021, 62(2), 213–222). Our aim was to increase the occurrence and comprehensiveness of documented discussions between next of kin (NOK) and the medical team, especially in vulnerable patients who may be unable to advocate for themselves.

Methods

We conducted a retrospective, cross-sectional analysis of patient notes across two PDSA cycles. NICE guidelines NG27, NG97 and NG96 provided an audit standard. Patients were identified as at-risk of poor communication if diagnosed with dementia, cognitive impairment, addiction, learning difficulties or needing an interpreter. Targeted intervention prior to re-audit included education of the medical team and introduction of a written prompt within the patient's notes.

Results

25/55 patients were identified as at-risk in cycle one, with 39/71 patients at-risk in cycle two. Post-intervention, the number of at-risk patients with a documented NOK discussion increased from 74% to 82%. Patient treatment plan discussions increased from 81% to 97%. Discussions, where applicable, regarding escalation of care, Deprivation of Liberty Safeguards (DoLS), capacity and Mental Health Act (MHA) slightly decreased. Conversations regarding patient consent for data sharing were rarely documented.

Conclusion

Our intervention increased the proportion of documented patient discussions; however, it did highlight the need to improve the frequency of documented conversations surrounding escalation of care, DoLS, capacity and MHA. This has provided impetus for further improvement projects.

Introduction:

Postural Hypotension is a very common presentation in the elderly population. Appropriate knowledge to record postural hypotension & non-medicinal management for this is very important among MDT members working in the care of the elderly wards.

Method:

We set out a questionnaire to assess the knowledge among MDT ( multidisciplinary) members. An educational programme was initiated to improve the knowledge among MDT members. A complete audit cycle was done and the knowledge was reassessed with the same questionnaire based on the principles of the PDSA (Plan, Do, Study & Act) cycle.

Results:

It showed that the correct way of checking for postural blood pressure improved from 52.4% to 92% in recording the blood pressure. Correct identification of postural blood pressure improved from 33.3% to 88%. Self-rating of confidence to identify correctly postural blood pressure improved from 47.6% to 64% among the MDT Members. It was difficult to compare the answers about non-medicinal methods and exercises to help postural hypotension as there was heterogeneity in answers. It was also not possible to compare the impact of individual interventions on the alleviation of postural blood pressure.

Conclusion:

Good improvement in the recording and non-medicinal management of Postural hypotension was observed in both the wards among the MDT Members. It is very important to have good knowledge and understanding in the management of this common condition as it helps in the identification and better management.

Introduction: NICE guidance recommends that doctors need to identify patients who are approaching their final year of life, through the utilisation of tools such as the Clinical Frailty Score (CFS). The 'Getting it right first time' (GIRFT) document recommended that all local health systems identify older people in the last phase of life and offer them Advanced Care Planning (ACP). Wigan has a large population of frail patients who would benefit from ACP discussions.

Aim: Initiate a strategy for identifying patients with severe frailty and establish a process for implementing ACP.

Method: Retrospective discharge data was used to identify patients aged >65 years, with a CFS of >7, over an 8-week period. The cohort was examined to see if they had been recognised as a patient who would benefit from ACP, or if an aspect of ACP had been completed during their admission. In total, 19 patients were identified, of which 6 were included and 13 were excluded.

Results: Initial data showed that we were poor at identifying and completing ACPs for patients with severe frailty. No advanced care planning decisions (0%) were taken during this period. Education (PDSA cycle 1) on ACPs for the ward doctors led to an improvement regarding ACP discussions. However, we were still poor at identifying severe frailty. Education (PSDA cycle 2) for nursing staff was undertaken, which highlighted inaccuracies with calculating CFS. Further PDSA cycles including a geriatric frailty score assessment, introduction of Electronic Palliative Care Coordination Systems (EPACCS) and frailty posters and cards.

Conclusion: Severe frailty is an end-of-life state and should trigger a healthcare professional to identify and sensitively discuss end of life needs and preferences. ACP should be disseminated to other healthcare professionals to allow them to act in accordance with the patient's wishes or best interests.

Introduction

Covid has had a devastating effect on the Elderly, resulting in deconditioning, increased falls and loneliness. Tailored exercises can reduce falls in people aged over 65 by 54% and participation in physical activity reduces the risk of hip fractures by 50%, currently costing the NHS £1.7 billion per year in England. This 8 week intervention delivered by trained volunteers in patient’s homes, aims to reduce deconditioning, loneliness and the risk, incidence and fear of falling (FOF) amongst frail patients post-discharge from hospital.

Method

A gap in service was identified in Frail patients discharged from hospital, at risk of falling and awaiting community physiotherapy. A steering group was set up including acute and community therapists, volunteers and carers to design a collaborative intervention to bridge the gap. At risk patients were identified and referred by ward therapists supported by the hospital volunteering team. Volunteers were trained to deliver an 8 weeks programme of progressive exercises in patients’ homes with additional signposting to appropriate statutory and voluntary services. Qualitative and quantitative outcome measures were taken at week 1 and week 8 of the intervention

Results

• 91.5% total health outcomes improved or maintained by average
• FOF reduced by 22.5%
• 180 degree turn improved by 43%
• 60 sec Sit to Stand improved by 14.75%
• Timed Up And Go improved by 15.5%
• Confidence to cope at home improved by 15% 
• Pain / discomfort (self-reported) improved by 18.75% 
• Overall health (self-reported) improved by 8.5%

Conclusion(s).

Targeted exercise at home with skilled volunteers can improve functional fitness and health outcomes in a frail elderly population at risk of falls when discharged home from hospital. The programme increases patients’ connectivity to local voluntary and community sector services. Volunteers’ mental health improves by engaging in meaningful service.

Background: Weight loss in the older adult is often multifactorial and can be associated with increased morbidity and mortality. Our quality improvement project focused on nutritional care of patients 75 years or older. This hospital has a standardised Nutrition and Hydration Policy based on NICE guidelines to prevent malnutrition in hospital inpatients including weighing patients every 72 hours, daily screening and food/hydration charts. Our project aimed to increase adherence, with a focus on increasing the percentage of patients being regularly weighed over a 6-month period to 90%.

Methods: Our stakeholder analysis highlighted the multidisciplinary nature of our project, particularly involving the healthcare assistants. The percentage of patients weighed within 72 hours was recorded weekly. The first PDSA cycle introduced the project and gained buy-in from the MDT, highlighting required weights in MDT meetings/board rounds. The second cycle included an education session for doctors. The third cycle involved a poster in each bay aiming to act as a prompt and promote patient and family involvement.

Results: Our run chart shows that following our first two PDSA cycles eight consecutive results were higher than the baseline (40% of patients weighed). Results ranged from 70-90%. Following the third intervention compliance returned to baseline but coincided with significant disruption to the ward structure and team. Our successful intervention of nutritional teaching was then repeated as a fourth PDSA cycle and the mean returned to 80%.

Conclusions: Nutritional care requires multidisciplinary involvement. The educational session had the most impact and in future could be delivered to additional MDT members. Disappointingly the poster did not stimulate patient or family participation. We would like to create an ethos on elderly wards where nutrition routinely features in ward-based comprehensive geriatric assessments. Future plans hope to further engage patients and families as visiting restrictions eased.

Introduction

Ambulance offload delays at the Emergency Department (ED) are linked to adverse outcomes. By 2030, 25% of patients attending the ED are projected to be over 80 years old. Geriatric frailty syndromes can be difficult for triage systems to assess, leading to older people being allocated lower priority status and a higher chance of a 4-hour target breach vs a younger patient(1). We assessed whether ambulance offload time is associated with frailty, death or re‐attendance at an emergency department at a large regional centre. Methods Retrospective analysis of adult ambulance offload data from February to June 2022 looking at age, frailty (CFS), inpatient length of stay (LOS), ED re-attendance within 6 months and death.

Results:

We included 1000 people transported by ambulance to ED February to June 2022. >65 years old– 622 patients (47% Male). Mean 406.3 minutes’ offload, CFS 5.4, LOS 11.75 days, Age 80.21 (IQR 73-87), 193 re-presented (32.76%), 135 deaths (22.9%). <65 - 378 patients (52.9% Male). Mean 189 minutes’ offload, LOS 5.1 days, Age 43.81 (IQR 33-56), 116 re-presented (31.86%), 24 deaths (6.34%). Significant associations (P<0.05) for CFS vs LOS, CFS vs Average offload, Average offload vs Age and LOS vs Average Offload. There is a significant link with Death vs CFS (P<0.05) but not re-presentation vs CFS.

Conclusions:

Longer ambulance offload times are associated with greater 6-month mortality and re‐attendance for people presenting to ED who are older and have increased frailty. Those directly offloaded to OPAS had decreased LOS (5.1 days) and offload time (121 minutes’) despite a mean CFS 6.41, indicating a need to increase OPAS capacity including for direct offloads into OPAS.

Background:

Delays in documenting a valid DNACPR (Do not attempt cardiopulmonary resuscitation) form in medical notes, for patients with advanced decisions, presses the cardiac arrest team to make difficult decisions about resuscitation, with little time to establish the patient’s wishes. This removes the right, for some patients, to die with dignity and peacefully. Local policy states patients with DNACPR forms should have this reviewed by the senior clinician in charge of their care as soon as is possible.

Aim:

To reduce the percentage of geriatric patients in Colchester hospital (with electronic DNACPR decisions) at 24 hours post admission without a signed DNACPR form in their notes to 30% from baseline of 44%. Methods: Baseline data was collected from geriatric wards on five dates in August and September 2021(n=122). For each patient, two online systems were reviewed (Evolve and My Care Choices Record) to locate existing indefinite DNACPR decisions. For these patients (n=25), the number of days between admission date and signed on the DNACPR form in medical notes was calculated. Ethics approval was gathered prior to data collection. Interventions: Posters in clerking locations, messages in doctors Whatsapp groups and presenting our first audit cycle at grand round. Re-audit was performed on three dates in June, July and August 2022 to see if our aim had been achieved.

Results:

Re-audit (n=98) proved reduction in the percentage of patients with a pre-existing DNACPR decision (n=30) at 24 hours post admission without a signed DNACPR form to 30%. In both cycles, 80% of patients with advanced decisions had a physical copy reinstated in their medical notes by 48 hours of admission.

Conclusions:

Further improvements are required to protect all patients from untimely DNACPR reviews. Audit results should be shared with colleagues to evidence the impact on patients and create motivation for behavioural change.

• Listen to “What Matters Most” to the individual however it is expressed.
• A gap persists for people with advancing frailty, dementia, neurodegenerative conditions whose end-of-life needs are NOT recognized NOR appropriately met but nonetheless have no acute specialist palliative needs. End of life is harder to recognize with slowly deteriorating trajectory. Challenge indiscriminate use of single condition protocols as underlying frailty becomes increasingly irreversible at this stage.
• Identification: CFS 7 – 9 registered with a local GP on acute frailty unit, other medical and surgical wards. From community referred to Rapid Response Team experiencing frailty crisis. Exclude if EOLC needs require hospital or hospice level input.
• GeriPall interventions: “Tender conversations” mainly listening. Review history from all sources. Explain including uncertainties of outcomes to patient and family. Whatever else is needed—accurate and appropriate Fast Track completion, Urgent (Advance) Care Plan both online and paper copies
• Extensive medication review particularly deprescribing of items no longer of net benefit. Prescribe as required for symptom management.
• Harness existing pathways including ward discharge coordinators, D2A, community therapy, 2 hour urgent care MDT response
• In community: advise patient’s own GP and selectively use Palliative Care Coordination Hub, specialist palliative care, Care Home Support Team, district nursing, SALT, social care… (voluntary sector)
• Post discharge, Consistent phone follow up as soon as possible and sometimes visited. Ability to prescribe, review situation. Away from the large institution it is easier for death to become a social phenomenon as much as a medical one. 
• Survey post-bereavement. Very limited due to admin staff shortage but individual feedback from relatives positive. One Datix from discharge team fully investigated for learning purposes. 
• Outcome measures. 72 patients in 4 months, mostly from acute hospital. 19 RIP to end of March 2022. Average no of days for 10 sample patients: in index admission prior to GeriPall intervention =17.3, after GeriPall  =3.1, previous 12 months in hospital =11, Days out of hospital under GeriPall=40
• Funded by winter pressures money 2021-22 and being sought for this winter.
• Shortlisted for HSJ Patient Safety Awards Care of the Older Person
• Hopes for future: funding, multidisciplinary staffing, systematic patient identification and referral. Data collection, MDT review post discharge and development and learning opportunities.