CQ - Patient Safety

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

Older patients admitted to the emergency department (ED) do not have a pharmacist-led medication review within the comprehensive geriatric assessment (CGA), yet the presenting complaint can be attributed to overprescribing and problematic polypharmacy. Taking ten or more medications increases the risk of hospital admission by 300% due to adverse drug reactions (ADRs)1, therefore a medication review can reduce this outcome by optimising current therapy2. Responsibility of safely transferring this medication information between care settings is a healthcare professional's duty, as the rate of error is 30 - 70%3.

Method

Patients were identified by the ED Frailty Team according to local frailty criteria, including patients > 65 years presenting with delirium, a fall and/or multi-morbidities. Medicines reconciliation was carried out by the frailty pharmacist, and medications optimised to reduce future harm with investigations prompted where needed. Interventions were categorised. A summary plan was written to the General Practitioner (GP) and each patient was followed up after 4 weeks to assess if received and actioned appropriately.

Results

73 medication reviews were conducted for patients (mean age 84.4 years) from June to September 2022, majority presenting with fall (69%). High-risk medication review was most common intervention (90%), followed by counselling (50%). 92% patients required a pharmaceutical intervention (n=208). GP plans were actioned for 65% patients in Primary Care.

Conclusion

ED frailty pharmacist's input reduced inappropriate polypharmacy and optimised medication for this patient cohort, with majority of care plans carried out appropriately following discharge. A future study could examine re-admission rates of patients in comparison to those without a frailty pharmacist's input.

References

1. Payne RA et al. British Journal of Clinical Pharmacology 2014; 77: 1073 – 1082.

2. Department of Health and Social Care, 2021. Available at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1019475/good-for-you-good-for-us-good-for-everybody.pdf. Accessed 19/1/23.

3. Department of Health, 2011/2012. Available at: www.wp.dh.gov.uk/healthandcare/files/ 2011/01/outcomesglance.pdf. Accessed 19/1/23.

Introduction

There has been a recent shift in guidelines regarding HbA1c targets in the frail population. NICE (June 2022) advocate individualised HbA1c targets for frail patients with diabetes in circumstances where the long-term benefit is uncertain or when a tight glycaemic control would increase the risk of poor clinical outcomes. This is backed up by randomised control trials that have showed that Hba1c levels < 53 mmol/mol (7%) because of anti-hyperglycaemic therapy are associated with increased morbidity and mortality in frail patients with diabetes.

This led us to explore the current standards with regards to HbA1c review and consequent anti-hyperglycaemic deprescribing in frail patients in Hereford County Hospital.

Methods

Two audit cycles have been completed from March - June 2024 with a total sample size of 28 patients. Inclusion criteria were patients aged over 65 with a history of diabetes and a Rockwood Frailty score of 5 or more.

Results

The results of the first cycle showed that only 20% of the study group had their HbA1c reviewed. Only one had evidence of de-prescribing considerations. After the first cycle, a poster was created highlighting the importance of considering deprescribing for frail patients. The results of the second cycle indicated improvements following the poster display with 22% of the study population having had their HbA1c reviewed with subsequent considerations to de-prescribe. Furthermore, the poster generated positive informal feedback and stimulated conversations with colleagues about deprescribing.

Discussion and conclusion

For frail diabetic patients presenting to the Emergency department, deprescribing their diabetic medications is often not considered. They may be on medications that could be potentially causing more harm than benefit. Staff education appears to have a positive benefit, but more work needs to be done to ensure that deprescribing is considered for these patients.

Introduction

Delirium has a significant impact on morbidity and mortality. It is also associated with an increased level of institutionalisation at discharge and increased length of stay. Therefore, a diagnosis of delirium should always be considered with an assessment of risk factors. The aim of this project was to ensure 100% of patients on Geriatric wards have a diagnosis of delirium considered via the 4AT as per NICE guidelines.

Methods

A Plan-Do-Study-Act methodology was utilised with an initial audit exploring identification and documentation of delirium diagnosis. A Lanyard Prompt Card was then distributed to all physicians with the 4AT score illustrated. A departmental teaching session about Delirium was delivered to all juniors. A re-audit was conducted to assess impact.
 

Results

Of the 41 patients evaluated initially, 50.7% (21) were suspected to be delirious. Of these, 9.5% (2) had been assessed for delirium on the same day delirium was suspected. Of 38 patients, post-intervention audit revealed 36% (14) were suspected to be delirious and of these patients, 43% (6) had a 4AT score on the same day.

Key conclusions

This project revealed 4AT assessments were approximately tripled in patients suspected to be delirious post-interventions. There remains scope for improvement in confidence and skill of documenting assessments to meet the NICE recommendations and potential to explore barriers. Ultimately, we aim to expand across all medical and surgical wards to upskill all MDT members on identification and management of delirium

Introduction

Incidents and complains are an important form of learning for healthcare institutions. The learning is often shared via huddles, handovers, emails and learning alert bulletins. In the older persons medicine (OPM) department at James Cook University Hospital, we identified that there may be a role for whole team in-situ sim to not only facilitate learning around important and highly relevant topics but also improve the education provision for nurses and healthcare assistants who have less access to education compared to their doctor colleagues and improve whole team communication.

Methods

Initially a working group including a consultant, advanced clinical practitioner, SIM training facilitator, liaison psychiatry nurse, teaching fellow and ward manager was set up to organise a pilot session. Following the success of this session the training was initially organised to be monthly, arranged by the advanced clinical practitioners, facilitated by the sim technicians. The ward managers fully supported the training and facilitated the attendance of the ward staff. The clinical director identified topics for learning from incidents and complaints and there was support from the OPM registrars and teaching fellow. It quickly became so popular amongst staff that the session frequency was increased first to fortnightly and is now run weekly.

Results

The feedback was excellent. From the attendees, to the sim trainers who said that the OPM department had been the most enthusiastic about ward-based training. The anonymised and entirely positive feedback from the sessions was that they were interesting, informative, and relevant to clinical practice.

Conclusion

Using in-situ simulation training on the older persons medicine wards to share learning from incidents and complaints is not only practical, but incredibly well received by staff of all disciplines.

Introduction
In older adults, anticholinergic burden (ACB) is associated with serious adverse effects
including delirium, falls, functional decline, cognitive decline and death. We carried out a quality improvement project in a geriatric ward, aiming to reduce the percentage of older adults with high ACB scores on discharge by 15% from a baseline of 48% over a period of 3 months.
 

Method
A pre-interventional analysis of all patients discharged from a single acute geriatric ward in
Changi General Hospital was performed. A pre-intervention survey was conducted to assess awareness among physicians of ACB and tools used. Fish-bone diagram, pareto chart and driver diagram were used to identify root causes, highlight the barriers and to prioritise
interventions. Interventions in the form of educational posters on ACB, non-
pharmacological management of delirium and behavioural symptoms of dementia were made available at the ward. ACB scores were generated for all patients on discharge, using
an online ACB calculator 1 , which combined the use of 2 validated scales: anticholinergic
cognitive burden scale 2 and the German anticholinergic burden scale 3 .

Results
396 patients were included in the analysis. Median percentage of patients with high ACB scores (≥3) on discharge was reduced from 48.4% pre-intervention to 16.1% post- intervention. Out of 14 physicians surveyed pre-intervention, 21.4% was unaware of theterm “ACB” and availability of ACB scoring systems.

Conclusion
An education approach is effective in raising awareness and reducing use of anticholinergic medications in an acute geriatric ward. This highlights the importance of incorporating ACB awareness and the tools into geriatric department teaching programmes.
References
1. ACB Calculator. (n.d.). https://www.acbcalc.com/
2. Boustani M, et al. Ageing Health. 2008. 4(3). 311-320.
3. Kiesel EK, et al. BMC Geriatr. 2018. 18. 239.

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

Venous thromboembolism (VTE) risk following acute stroke is high. Current guidelines recommended intermittent pneumatic compression (IPC) stockings for up to 30 days in those who are immobile following acute stroke. The concern post-stroke is haemorrhagic complications when using low molecular weight heparin (LMWH). The CLOTS3 trial favoured IPC for safety in the first 30 days. However, in many cases, doses suitable for VTE prophylaxis can be used but with caution if IPC cannot be used.

Method

A spot audit of patients current VTE prophylaxis was undertaken in a stroke rehabilitation unit to look at IPC and LMWH usage. 10 patients were selected at random to look retrospectively at choice of VTE prophylaxis and how this changed during their admission.

Results

35 patients' full records were available. Five patients were within 30 days of admission. 12(34.3%) were anticoagulated, predominantly for atrial fibrillation. 15(42.8%) were on LMWH. VTE prophylaxis was not indicated in 3(8.6%) patients. 5(14.3%) were on no VTE prophylaxis. Of the 10 patients reviewed in depth 7(70%) had used IPCs for a time during their admission. IPCs were discontinued in 3 after starting anticoagulants and in 4 at the patients request. In 3 of the patients where IPCs were not tolerated there was a delay in starting an alternative form of VTE prophylaxis. Complex decisions were required in a patient started on LMWH post-neurosurgical intervention.

Conclusions

Decisions regarding VTE prophylaxis following acute stroke are complex. Changes are required frequently during inpatient admission and delays occur both on admission and when non-specialist team members are not confident in prescribing an alternative to IPCs. We would recommend a prompt to ensure VTE prophylaxis is considered on initial ward round and regular review during admission with anticipatory consideration of an alternative to IPCs by specialist clinicians if they are subsequently not tolerated.

Pulmonary embolism (PE) is the third most common among acute cardiovascular diseases, after myocardial infarction and stroke, with a significant mortality rate. At Portsmouth University Hospital's acute medical and respiratory departments, inadequate understanding of pulmonary embolism diagnosis and management, which led to unnecessary investigations and medications putting the patients at risk of the side effects and complications of that, was the main impetus for initiating this audit. The hospital did not adhere to the NICE recommendation of regular interim anticoagulation for patients awaiting imaging for probable PE. A significant number of patients unnecessarily admitted to the hospital due to PE could have benefited from outpatient treatment. We collected data for eight weeks both before and after the implementation of the new hospital PE pathway, following a baseline audit and PDSA-based problem-solving, which underscores the significance of accurately utilising the Wells Score and PE rule out criteria (PERC). We obtained PE diagnosis criteria from NICE standards for comparison. The new hospital PE pathway was a result of the initial audit. The results from the re-audit showed an improvement in documentation and calculation of the Wells score from 16.1% to 66.1%, the PERC score from 9.1% to 58.3%, and the PE severity index (sPESI) score increased from 9.1% to 58.3%, as well as an increase in the number of junior doctors who initiated the PE pathway from 19.6% to 41.9%. Additionally, the proportion of inappropriately requested investigations, such as D-dimer and CTPA, was reduced. Also, the number of CTPAs requested in line with the guidelines increased from 11.11% to 52.27%, and the diagnostic yield of PE on CTPAs increased from 36.08% to 64.85%. A simple diagnostic pathway resulted in a decrease in unnecessary investigations and an increase in the diagnostic yield of PE.