CQ - Patient Safety

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.

Background Clinicians are increasingly aware of the association of frailty syndrome and adverse outcomes. The British Geriatric Society recommends that clinical frailty scores (CFS) are assessed for all patients on admission to surgery, to optimise peri-operative care.

Method For in-patients over one month (June 2023), the concordance with guidelines was recorded and any ‘missing’ scores retrospectively completed (Rockwood CFS). Clinical metrics included length of stay.

Results 110 patients were admitted under vascular surgery. The median age was 67 (IQ 61-79). 73 (66%) were aged >65-years and 42 (58%) of these patients were frail or at risk of frailty (CFS 4-9); 37% of all admissions. 10 (14%) patients >65-years had their CSF documented, only 3 (4%) had this documented in an easy-to-access “AdHoc” form. 3 frail patients had formal assessment by a geriatrician during admission. Higher frailty score directly correlated with longer hospital admission (p=0.002), the average stay was 4 days longer in the frail cohort.

Conclusion Despite the high prevalence of frailty among vascular admissions, the overwhelming majority did not have CFS scores recorded in line with BGS Guidance, perhaps increasing risks for these patients. Ongoing quality improvement has focussed on educating foundation staff responsible for clerking surgical patients on the importance of assessing and documenting CFS.

 Introduction:

Intracerebral haemorrhage (ICH) accounts for 10-20% of strokes worldwide. Mortality is high at 40% and survivors might suffer from severe disabilities that massively impact quality of life and independence. Diagnosis and treatment are straight forward. A non-contrast CT head scan is diagnostic. Treatment is focused on prompt anticoagulation reversal and blood pressure control, with consideration of surgery in appropriate cases and admission to an acute stroke unit or an intensive care unit.

Methods:

Two PDSA cycles of 28 and 29 patients were completed in the acute stroke Unit between 2020-2022 (8 months apart), Data gathered included blood pressure readings on admission and intervention to control it. The percentage of anticoagulation reversal was noted. We recorded if each patient was admitted to the stroke unit and if the patient was discussed with neurosurgery. Interventions post-first PDSA cycle included implementing a formal bundle of care, reflecting ABC-ICH practice, formalisation of the departmental guideline on blood pressure control, anticoagulation reversal and neurosurgical referrals. Teaching sessions were delivered to junior doctors and stroke assessor nurses.

Results:

Anticoagulation was reversed in 30% patients on anticoagulant (1% improvement). BP medication was given in 62% compared to 52% yet control within 1 hour was achieved in only 12.5 %. All patients were admitted to ASU (97 % previously). There was an evident improvement in decreasing over-referral to the neurosurgeons, 50% compared to 76% previously, and also in terms of selecting the proper patient to refer where 100% of hydrocephalus patient was referred.

Conclusion:

Although the re-audit has shown consistency in admitting all patients to HASU and decreased numbers of referrals to neurosurgery, it showed an unacceptable shortage in the key management of intracerebral haemorrhage, specifically in two major areas, reversal of anti-coagulation treatment and prompt blood pressure management. Further quality improvement work is being undertaken.

Between 2016 and 2021, HSC Trust reported 1,383 choking-related adverse incidents, highlighting a pressing concern for patient safety. This Quality Improvement (QI) Initiative was developed within a Nursing Home specializing in caring for residents with learning disabilities who faced an elevated risk of eating and drinking difficulties. The primary objective was to enhance safety during meal times by integrating a structured safety pause, aligned with the "7 Rights" framework. The initiative leveraged various QI tools, including process mapping, PDSA (Plan-Do-Study-Act) cycles, structured observations, and interviews.

Results of the initiative demonstrated a notable increase in patient satisfaction, a boost in staff confidence, and a reduction in near-miss incidents. The success of the program prompted its expansion to other nursing homes, involving families in the process. To further support patient safety, each staff member and family member now possesses a small card outlining the "7 Rights," which can be readily utilized before assisting patients with eating and drinking difficulties. This initiative represents a valuable step forward in safeguarding vulnerable individuals and has the potential to positively impact patient care across various healthcare settings.

Aims

This closed loop audit aims to primarily assess and improve the number of geriatric patients who fell on elderly wards in a District General Hospital using cost effective methods. The secondary aim is to improve documentation of falls and assess for contributing factors. Hypothesis The primary hypothesis is that number of falls can be reduced through better nursing training and co-locating high risk patients. The secondary hypothesis is that improvements in documentation can be made with nursing training specified to falls and to corroborate risk factors with existing literature.

Methods

The first cycle was conducted between February 2021 to May 2021. Patients who were deemed high risk of falls, defined as over 80 years with at least 1 previous fall, were co-located. Nursing staff were provided with falls related training and how to report falls. The audit was repeated between the months of February 2022 and May 2022 to prevent seasonal bias. Results collected using the computerised internal patient records and paper documents. The number of falls, in addition to demographics, comorbidities, medications and complications were collected and compared.

Results

It was shown that cost- effective measures implemented in this audit significantly reduced the number of falls- down from 50 to 29 total falls across the same time period. We showed polypharmacy is a contributing factor to increased falls, with anti- hypertensive medications recurring as a repeated offender. 90% of those who fell were recurrent fallers, highlighting the importance of early identification of those at high risk.

Conclusion and further studies

This audit has highlighted the importance of simple, clinically effective and cost- effective measures in falls prevention. Further improvements, such as falls alarm for patients and refurbishing of ward layouts have been suggested by nursing feedback. Once implemented, the wards can be re- audited for further falls prevention.

Postural Hypotension also known as orthostatic hypotension is defined as an abnormal drop in blood pressure on standing after periods of sitting or lying down, with a sustained reduction of systolic blood pressure of at least 20mmHg and/or diastolic blood pressure of at least 10mmHg. The prevalence of postural hypotension increases with age with one in five community-dwelling adults over the age of 60 years old and one in four people in long term residential care, which will ever grow with the growing elderly population. By discussing with patients on our ward it was clear that patients were aware of the pharmacological options including Midodrine or Fludrocortisone but patients were less aware of the non-pharmacological management options which are just as successful. We decided to audit whether or not the patients suffering with postural hypotension were aware of what the non-pharmacological options were and after discussing the options to hand them a poster including 4 things to avoid and 7 things they could do moving forward. The 4 things to avoid were: 1. Hot Weather 2.Hot Bath 3.Alcohol 4.Large Meals. The 6 things they could do were: 1.Sitting and standing slowly 2.Drink plenty of fluids as a bolus 3. High Salt Intake 4.Head-tilt at night 5.Abdominal Binders 6. Compression Stockings 7. Physical Manoeuvres. During my time on the ward we have had 5 individuals with postural hypotension. When asked about the non-pharmacological options the average number they were aware of was 32% to compare with 80% on the pharmacological management. This number can definitely be improved moving forward hence our use of the poster on the ward and pamphlets for patients. 

Introduction:

Inappropriate catheterisation poses a risk to orthogeriatric patients both in the pre-op and post-op phase. Introducing a foreign object increases the risk of infections, sepsis and seeding of infection to the newly implanted prosthetics for surgical neck of femur (NOF) fracture patients. Furthermore, catheterisation also increases the length of hospital stay and risks of bladder deconditioning and failed attempts at trial without catheter. Therefore, it is essential that nursing and medical staff are aware of the appropriate indications of catheterisation.

Method:

We retrospectively reviewed 40 patients within a one month period who were admitted to the orthogeriatric ward and underwent surgery for their NOF fracture. We examined whether catheterisation and indications were documented on the electronic patient records (EPR), we also reviewed where the catheterisation took place (e.g. on the ward or in the Emergency Department (ED)). Indications were compared to our hospital guidelines for catheterisation.

Results:

1 Patient had a long-term-catheter and was not used in the data analysis. Of the remaining 39 patients, 23 (60%) were catheterised. Majority of these cases (83%) were documented appropriately, with the most common indication being that of urinary retention (47%) especially in the post-op phase. However, 'NOF fracture/immobility' was the second most common documented indication (37%), majority of which (86%) were done in the ED prior to transfer to theatres/ward.

Conclusion:

NOF or immobility is not an automatic indication for catheterisation and catheterisation in these patients is not considered a routine pre-op measure for hip fracture surgery. More education needs to be done with the medical and nursing staff especially in the emergency department regarding this, including encouragement of use of other methods such as pads and bed-pans in the pre-op phase.

INTRODUCTION: In order to improve resident safety and reduce hospital admissions, the ‘Optimizing Bed Height Quality Improvement Study’ aims to raise awareness among healthcare professionals about the importance of ensuring optimal bed height to prevent falls and injuries in residents and to improve bed mobility.

The parameters from a 2015 study, ‘Analysis of the Influence of Hospital Bed Height on Kinematic Parameters Associated with Patient Falls During Egress', are taken into account when using intervention techniques.

METHODS: Residents aged 65 or over falling out of bed between January and June of 2022 were used as a pre-test measure. By maintaining a hip or knee angle just above 90 degrees, keeping the resident's feet flat on the floor, and ensuring that they can easily transition from sitting to standing and vice versa, the nurse and physiotherapist assessed the resident's mobility and determined the height of the resident's bed. An illustration of the ideal height is displayed on a poster that hangs on the wall above the headboard of the bed. Nurses visit each resident's room each day to ensure that the beds were in the ideal position and record this information in the monitoring system. The data obtained during the six-month period of intervention (July to December 2022) was compared with the pre-test results.

RESULTS: Results from a six-month intervention period (July to December 2022) were compared to those from a six-month pre-intervention phase (January to June 2022) with fourteen bed falls, there was a FIFTY PERCENT decrease in bed falls.

CONCLUSION: After a six-month clinical trial, the study revealed that older adults who had bed falls and trouble getting out of their beds had lower fall rates, suggesting that stakeholders' knowledge of the ideal bed height had increased.

Introduction
Mittens are used to facilitate necessary interventions safely in patients who lack the mental capacity adhere to them. A serious incident (SI) occurred at our Trust when a patient, with delirium, developed pressure ulcers to their wrists as a result of prolonged use of mittens. A subsequent investigation revealed that there had been inadequate skin checks and insufficient documentation, from the medical team, directing the use of mittens.

Method
A multidisciplinary QIP was initiated: • For the Medical team: An electronic “Mittens Request Form” was created. This included fields to document a mental capacity assessment, the best interest decision and a link to apply for Depravation of Liberty Safeguards. There was also a prompt to prescribe mittens on the electronic drug chart. • For the Nursing team: A pre-existing electronic mittens checklist form was updated to confirm that a daily skin check had been completed. The outcomes of the SI report and changes above were communicated to the department. After the QIP, a notes review was completed for all patients over the age of 65 years who had a mittens checklist completed before and after the interventions. Notes were assessed for documentation of a mental capacity assessment, communication of a best interest decision, prescription of mittens and completion of a daily skin assessment.

Results
Documentation of a capacity assessment improved from 9% to 47%. Communication with relatives improved from 0% to 35%. Prescription of mittens, on the drug chart, improved from 0% to 24%. Documentation of a daily skin assessment Increased from 0% to 94%

Conclusions
This QIP brought about improved documentation of best interest decisions related to mittens and ensured regular skin checks. The next stages will involve expanding the QIP to other departments within the hospital and reinforcing messaging about communication with relatives and prescription of mittens.

Title: Bone health assessment audit cycle at Queen Alexandra Hospital, Portsmouth (Audit ID 5474)

Background: Conducted in the Department of General Internal Medicine. Our focus group was elderly patients, especially women aged 65 and above and men 75 years and above as per NICE guidelines since these patients should have their bone health assessment done ideally.

Local problems: Osteoporosis is very common affecting approximately 3 million people. Over 5,00,000 fragility fracture occurs in the UK each year. Our audit aimed to find the percentage of patients who underwent bone health assessment and got bone protection treatment appropriately, thus checking our compliance with NICE guidelines. Hence keeping in line with patient safety.

Methods: A total of 45 patients’ data was collected from the medical wards in both the audit and re-audit. Data was collected from the patient’s case notes, previous clinical documents and medication charts. A questionnaire was used which entailed patient details, risk factors for osteoporosis and whether or not a bone health assessment had been done.

Interventions: We identified patients at risk of osteoporosis. Performed BHA with FRAX score calculation. Started them on appropriate treatment based on NOGG 2021 guidelines. Additionally, a teaching session was held after each audit to implement changes in the department and raise awareness about the importance of bone health assessment.

Results: The first audit showed that only 29 out of 45 patients (64%) had their assessment done. 41 patients (91%) had their assessment done in the re-audit showing a significant improvement of 26%.

Conclusions- Bone health is often overlooked and affects millions of people across the UK with a high risk of mortality and morbidity, affecting patients’ quality of life. Based on the comparative analysis, 26% more patients benefitted from the completed audit cycle.