CQ - Patient Safety

Introduction:

A Clinical Audit was recommended by the ME following identification of potential safety signal because of possible non-compliance with guidelines on Anticoagulation in AF. The audit data collection tool was developed in discussion with the Chief Pharmacist and took account of up-to-date prescribing guidance from the Integrated Commissioning Board (ICB). Aim of the audit was to identify if, as per NICE guidelines patients had: o Risk for stroke (CHA2DS2-VASc) and bleeding (ORBIT) is assessed upon new diagnosis of AF? o Made aware of their risk assessments and involved in discussion regarding risk -vs-benefit of anticoagulation o Anticoagulation prescribed as per national recommendations.

Objectives:

To ensure that patients with new diagnosis of atrial fibrillation are assessed for stroke and bleeding and involved in discussion regarding anticoagulation which is prescribed as per national recommendations. Methodology: This local audit was carried out by analysis of both electronic and paper-based patient records using an Excel spreadsheet for analysis. Data was then analyzed with the help of the Senior Clinical Effectiveness Advisor.

Results and highlighted risks:

It was observed that in most cases (82%), patients were not made aware about the condition and associated risk of stroke due to underlying AF. They were also not involved in discussion regarding commencing lifelong anticoagulation, and not explained the benefits and risks of anticoagulation. Omittance/Ignorance of anticoagulation upon new diagnosis of AF hence increasing the risk of stroke with lethal consequences of preventable death in 21% of patients.

Recommendations & Conclusion:

Formulation of “AF Anticoagulation Checklist” (based on NICE guidelines) ensuring every patient with a new diagnosis of AF has a repeat ECG for confirmation of diagnosis, CHA2DS2-VASc and ORBIT scores for risk assessment, their renal functions and coagulation profile checked, followed by discussion with patient regarding results of risk assessment and risk vs benefit of anticoagulation.

Introduction

Treating hypertension in older patients (>65y) remains controversial given limited evidence around optimising blood pressure in frailty. Although studies suggest improved cardiovascular benefit, NICE guidelines emphasise the need for careful clinical decisions to balance benefits and risks. This local audit assessed the appropriateness of antihypertensive regimens prescribed for older patients against NICE guidelines and STOPP/START criteria. Secondary aims assessed admissions related to antihypertensive medication, polypharmacy reviews during inpatient stays, and management of postural hypotension.

Methods

Retrospective chart analysis of 29 patients including adults > 65y admitted under Ageing and Complex Medicine consultants with diagnosis synonymous to hypertension, postural hypotension, or falls.

Results

A third of the cohort were on inappropriate antihypertensive medications on admission; 56% of these being contraindicated STOPP criteria drugs. 78% majority had medications reviewed, resulting in an improvement from 69% to 89% of patients being on appropriate antihypertensives from admission to discharge.  The admission diagnosis’ of at least 55% of patient cohort were related to antihypertensive medication. There was better compliance of checking lying and standing blood pressure (LSBP) within 48h admission but lower value of 36% was observed within 48 hours prior to discharge. Of those measured, a significant 74% and 50% of patients demonstrated positive postural drops on admission and discharge.  18% of all patients re-attended hospital within six months with similar diagnosis’.

Conclusion

Many older adults in the local area are admitted to hospital whilst on inappropriate antihypertensive regimens. Those admitted due to falls often experience symptoms caused by their medication effects. There is substandard dynamic assessment of lying-standing blood pressure during antihypertension management which likely contributes towards high rate of hospital readmission. Quality improvement measures such as targeted teaching sessions have since been undertaken to improve competence and confidence in clinicians managing hypertension. Further interventions to improve LSBP monitoring, primary care education and patient information provision are ongoing.

Introduction

Reduction in outpatient appointments during the COVID-19 pandemic and patient concern surrounding risk of contracting COVID-19 by attending day-case settings, resulted in delayed or cancelled medical treatments including Zoledronic Acid infusions as management for Osteoporosis. This, alongside recent research concluding that these treatments can be given safely as early as 1-2 weeks post-fracture, lead to the adaptation of protocol at Hull University Teaching Hospitals Trust in 2021, to provide rapid loading of Cholecalciferol over 6 days, prior to administration of Zoledronic Acid on day 7. However, some concerns remain surrounding the potential interference with bone remodelling and healing. This completed audit cycle evaluates the logistics and safety of this new protocol.

Methods

All patients over 60, admitted with neck of femur fracture who received Zoledronic Acid infusion as inpatient or outpatient in 2019 and 2021 were included in the initial and repeat audit respectively. Electronic records for the following 12 months were analysed evaluating for further fragility fracture and mortality rate.

Results

There was an increase in patients receiving Zoledronic Acid as an inpatient treatment from 21% in the initial audit to 97% in the repeat audit. There was a slight increase in mortality rate at one year from 14% to 19%. The percentage of a further fragility fracture within one year, remained stable at 7%.

Conclusion

The increase in inpatient infusions suggests more patients with significant frailty who would otherwise not have been able to attend outpatient settings, have been able to receive treatment. The mortality results reflect this frailer audit population. The absence of a substantial increase in the rate of further fragility fracture at one year; supports the earlier administration of Zoledronic Acid as a management protocol.

Introduction

Inpatient falls are a major cause of avoidable harm in patients on elderly care wards. Delays in identification of fall precipitants and recognition of sustained injuries increases morbidity, mortality and length of stay (Cameron et al, Cochrane Database Syst Rev. 2018 Sep; 2018(9)). Patients sustaining falls are often initially assessed by postgraduate year 1 and 2 doctors independently. We aimed to improve patient outcomes following inpatient falls through standardisation of the assessment and documentation following a fall in hospital.

Methods

Using PDSA methodology, incident reports and documentation of inpatient falls were reviewed retrospectively over three 28-bedded elderly care wards. A post-falls proforma was devised that covered various domains of the post-fall assessment and was distributed to doctors throughout the hospital. Following the intervention, a repeat PDSA cycle was performed prospectively over the same wards and the proportion of assessments fulfilling each domain was compared between the cycles.

Results

Medical assessment of 27 falls from November 2020 to January 2021 was compared to 31 falls occurring between February and May 2022. Use of the proforma in cycle 2 was limited to 8/31 falls following intervention. Post-intervention, the proportion of assessments fulfilling medication review (19% vs 35%, p=0.14) and anticoagulation status (41% vs 55%, p=0.28) was improved. The proportion fulfilling fall circumstances (89% vs 90%, p=0.85), medical precipitant (70% vs 61%, p=0.46) and ordering of appropriate imaging (93% vs 97%, p=0.47) remained high.

Conclusion

Standardisation of post-falls assessment and documentation can improve patient safety outcomes through reducing delay in recognition of medical precipitants of falls and identification and management of sustained injuries. Improved integration of a post-falls proforma into electronic systems is needed to maximise its clinical benefit and would be the target of a further PDSA cycle.

Introduction

This quality improvement project (QIP) aimed to determine whether the acute admission of patients with Parkinson’s Disease (PD) is meeting the current NICE guidelines in the appropriate prescription and timely administration of anti-parkinsonian medications (APM). The project evaluated the accuracy of prescriptions, quantified delays in medication administration, and established the causative factors for delays. 

Methods

This QIP was a retrospective study with two cycles analysed over a one-year period. Following consent and approval, notes for eligible patients meeting the inclusion criteria of a PD diagnosis being treated with APM’s, were retrieved. The records were analysed and reviewed against a data collection tool. Two criteria were established with a targeted compliance of 100% without exception: the first outlined that patients should have their APM administered on time without a delay of more than 30 minutes (criteria 1); the second appraised the accuracy of the prescription on drug charts (criteria 2).

Results

The combined cycles included sixty-five patients which were analysed based on the QIP objectives. In the first cycle, the compliance of criteria 1 was 21%, and criteria 2 was 58.6%. Following these results, key interventions were implemented in the trust: regular teaching on APM’s, commencement of mandatory PD training, posters created and displayed, stocks of APM kept in the emergency department, new guidelines for PD management published, and ‘Give it on Time’ stickers clearly placed on patient notes with a diagnosis of PD. Following the intervention, the second cycle’s compliance of criteria 1 improved to 65% and criteria 2 increased to 88.5%. Notably, after interventions, more patients (36%) were empowered to self-administer their medications. 

Conclusions

Overall, this QIP identified a low compliance with the standards set by NICE guidelines in the first cycle. Following the key interventions, the compliance improved significantly and this subsequently enhanced patient safety and outcomes.  

Introduction 
In-situ simulation has been shown to improve professional skills, team working and clinical care via social learning theories, benefiting all of the wider multi-disciplinary team – including nursing, physician associate and administrative colleagues – in addition to medical staff, by building camaraderie and a sense of belonging. Thus, a novel in-situ simulation training programme was created within the Department of Medicine for the Elderly at Broomfield Hospital; additionally forming part of an ongoing quality improvement project in medical education. 

Method 
Cycle 1: 30-minutes long sessions held on frailty ward on ad-hoc basis. 
Cycle 2: 30-minutes long sessions held on base ward of doctors on an ad-hoc basis, with select equipment provided. 
Pre- and post-teaching questionnaires were circulated to participants, with data scored via Likert scales assessing pre- and post-teaching confidence in reviewing an acutely unwell patient, familiarity with ward staff and equipment, and confidence in escalating patients, and handover. Each cycle ran over 4 months, with new participants per cycle. 

Results 
Significant improvements in key metrics were noted following attendance at a simulation session. Following the first cycle (n=20), 75% of participants were confident above neutral midpoint in reviewing an acutely unwell patient post-attendance, compared to 20% pre-teaching. Confidence in escalation of unwell patients rose from 65% to 95%, and confidence in handovers increased from 45% to 85%. Following the second cycle (n=23), confidence above neutral midpoint in reviewing an acutely unwell patient rose from 13% to 69%. Confidence in escalation of unwell patients increased from 52% to 65%, and confidence in handover rose from 30% to 65%. 

Conclusion 
The implementation of in-situ simulation has been shown to improve confidence in reviewing an acutely unwell patient, along with other metrics related to patient care and communication, highlighting the need for high fidelity simulation in medical education within hospital settings.

Aim: We aimed to improve the assessment, documentation, and management of inpatient falls by introducing a memorable CARE poster and promoting the use of a digital falls proforma for both nurses and doctors. This initiative aims to standardize practices and enhance patient safety. Method: Cycle 1: Initial data revealed poor documentation of falls, with missing elements such as Clinical Frailty Scale (CFS) scoring, medication review, pain management, and lying/standing blood pressure (LSBP) measurement. These critical aspects were incorporated into the CARE poster. Cycle 2: The CARE poster and digital falls proforma were launched, accompanied by brief training sessions on the geriatric ward. These sessions encouraged resident doctors to prescribe analgesia and supported comprehensive documentation. We audited falls documentation before and after the intervention to evaluate improvements in recording relevant data. For the next cycle, we aim to engage a broader audience, including all medical and surgical teams, by conducting face-to-face campaigns and distributing email reminders. The focus will be on ensuring doctors and nurses complete every section of the proforma. Conclusion: The CARE poster and digital falls proforma have significantly improved falls documentation, ensuring the inclusion of critical elements like LSBP, blood sugar checks, and thorough physical examinations. It also highlights key management steps, such as requesting investigations, prescribing analgesia, and reducing polypharmacy. Our project demonstrated a 40% improvement in LSBP documentation and medication review. However, analgesia care improved by only 2%, despite 85% of post-fall patients sustaining injuries. Further education for doctors and nurses is needed to address this gap. Currently in its third cycle, this QIP continues to evolve, with ongoing implementation and a planned audit. We are optimistic that it will enhance clinical practice and uphold our trust's core value: putting the patient first.

Introduction

The UK population is ageing quickly, with the number of individuals over 65 rising from 9.2 million to 11 million in the last decade. This increase has led to more comorbidities and complex treatment regimens, often referred to as polypharmacy, which can cause adverse effects, increase admissions, mortality and high healthcare costs. To address these issues, the NHS is adopting a patient-centred approach to optimise medication use and improve outcomes. This includes evaluating patients, setting shared goals, and identifying unnecessary or harmful medications. Data was gathered from community patients referred to the Early Intervention Team (EIT), which aims to ensure safe discharges and prevent hospital admissions related to falls, frailty, and cognitive or functional decline in Suffolk.

Method

Data were collected from March to May 2024 for fifty-one patients aged 65 and older who received home visits from EIT and were on five or more medications. Medical records were reviewed to identify medications associated with health deterioration and to assess the frequency of medication reviews, along with related costs. A survey was also conducted to evaluate the impact of their medication regimens on quality of life and gauge interest in reviewing and potentially reducing their medication burden.

Results

Out of fifty-one patients, 90.2% adhered to their medication regimen, but over half (54.9%) did not understand its purpose and reported side effects, including falls (82.4%), memory problems (64.7%), and constipation (54.9%). Additionally, 72.5% wanted their medications reviewed. Twenty-two patients GP were promptly contacted. Notably, one patient's annual medication cost was calculated as £5,256.96.

Conclusion

Polypharmacy leads to high financial and health costs, yet medication reviews are often inadequate or unavailable. The authors suggest conducting regular reviews in outpatient falls or frailty clinics to monitor adherence and tolerance. Further research is needed to ascertain the benefits of this practice.

Introduction

Treatment escalation plans (TEP) guide level of life sustaining therapeutic interventions that should occur for each patient admitted to hospital and can prevent inappropriate and undignified interventions. However, implementation of TEP in routine clinical practise has been ad hoc partly due to the paucity of literature on their benefits. Our aim was to systematically review the literature to ascertain the use and benefits of TEP in adults.

Methods

A systematic search for studies reporting TEP use were performed in the databases OVID Medline, Embase, Scopus and Web of Science. Search terms were ‘Treatment Escalation Plan’ Treatment Limitation, ‘Therapy Escalation’, ‘Escalation of Care’, ‘Palliative’, End of Life’, ‘Advanced Care Plan’. Exclusion criteria included studies prior to 2007, systematic reviews, case reports and letters.

Results

468 records were retrieved, 117 duplicates removed, 351 records were screened. 302 were excluded by date or relevance. Of 49 eligible records, 39 were excluded by criteria or unavailability of full text articles. 10 Studies using case control and quality improvement methodology conducted between 2010-2022 involving 1614 patients were subject to a narrative review. 8 different TEP proformas were used. All studies reported an increase in TEP use across all clinical settings and after each PDSA intervention ranging from 78%-100%. TEP reduced the frequency of non-beneficial interventions and was associated with an average saving of £220 per patient.

Conclusions

TEP lead to more frequent and proactive discussions with patients on ceilings of care and provide clear guidance to clinical staff out of hours, facilitate patient handover over successive shifts and enable proactive discussions with critical care. We identified the need for TEP to be successfully implemented in a unified manner across all healthcare facilities in order to improve patient care, reduce the burden of non-beneficial interventions and align with the NHS Long Term Plan.

Introduction.

The National Early Warning Score (NEWS) (2017) incorporated new confusion as a category for consciousness. NEWS2 is evidenced to have high specificity but low sensitivity in detecting delirium.

Methods

Morriston Hospital 261 patients assessed. Consciousness, overall NEWS2 score and AMT4 recorded. 227 NEWS2 charts available. 208 patients recorded as alert. 44% (n=87) scored less than 4 on AMT4 ,55% (n=48) didn’t have documented past medical history (PMH) of cognitive impairment. Data missing for 14 patients. Ysbyty Gwynedd 178 patients assessed.161 recorded as alert. 58.4% patients scored less than 4 on AMT4, 77% had no PMH of cognitive impairment. Data missing for 15 patients. University Hospital Llandough. 40 patients; 38 patients were marked as Alert, 2 were excluded from observations.32.5% (n=13) had a diagnosis of possible or definite delirium. An electronic survey coupled with training delivery of 103 Health Care Workers (HCW) and 112 Registered Nurses (RN) was undertaken at Morriston. 39 HCWs ( 37.8%) and 31 RNs ( 27.6%) weren’t confident in the use of NEWS2 in regards to acute confusion. Training was offered on a 1 to 1 basis for these 215 staff members.

Results

Post intervention, 221 patients were assessed at Morriston, 209 marked as alert. 2 patients had been identified as having a new confusion and 10 patients did not have their consciousness recorded. Of the 209 marked alert 42% (88 patients) scored less than 4 on AMT4; 53 had no PMH of cognitive impairment. Training yielded little benefit.

Conclusion

The accuracy of recording consciousness has wider implications on the use of the NEWS2. NEWS2 uses routine observations and delirium assessment is variably implemented meaning routine information is not always available. The NEWS2 should be used in conjuction with other tools developed for delirium e.g 4AT and SQiD.