CQ - Patient Safety

Introduction: In Scotland, more than 18,000 older people are admitted to hospital after a fall each year. One in three people over the age of 65 experience a fall at least once each year (1). Neurological examination is an essential part of the initial assessment of these patients in hospital and can determine the cause of falls such as stroke, peripheral neuropathies and Parkinson’s disease. Local anecdotal evidence suggested that this was often not carried out, with the potential for delayed diagnosis and treatment.

Method: Baseline data was collected from clinical notes of admissions to the care of the elderly (COTE) wards at University Hospital Hairmyres (UHH) over a 1-month period. Multiple departmental education sessions were arranged to highlight to medical staff the importance of neurological examination in patients presenting to hospital following a fall. Following these sessions the data collection cycle was repeated. A poster has now been designed highlighting common causes of falls and in particular emphasising the importance of performing a neurological examination, with a further cycle of data collection planned.

Results: 36.8% of patients admitted to COTE wards in August 2022 were admitted with falls, with only 23% of patients having a neurological exam documented on admission. Following the initial intervention, 30 patients’ notes were reviewed in January 2023. 56.7% of patients were admitted with falls and frequency of documented neurological examination had increased to 58.8%.

Conclusion: Educational sessions resulted in a 156% increase in documented neurological examinations for patients admitted with falls. We hope this improvement will lead to earlier identification of causes of patients’ falls, allowing prompt management. Our project is ongoing, with planned implementation of posters as a secondary intervention, with further data collection in due course.

References: 1. NHS Inform. Why Falls Matter. Available from: https://www.nhsinform.scot/healthyliving/preventing-falls/why-falls-mat… (accessed 27 November 2022)

Introduction - The POPS service (SOPAS) in Morriston Hospital receives over 300 referrals a year. However, many of these referrals did not meet service criteria. Inefficient direction of referrals has a negative impact on service efficiency and can result in poor patient experience and outcomes. This is a quality improvement initiative to increase the quality and suitability of referrals made to the service.

Aim - To implement a referral system able to offer safe, rapid assessment for surgical patients who would benefit from geriatrician-led intervention.

Method - We developed a list of criteria for referral to the service and included 47 referrals over a two-month-span for analysis. Two PDSA improvement cycles were then performed. The first cycle involved implementation of an automatic email response to referrals as they came in addressing the main safety concerns highlighted in the analysis. The second cycle involved setting up a new referral process via an online form to provide structure and prompts for key information to improve the content of referrals along with collecting service data prospectively.

Results - Prior to invention, many referrals missed key information. Almost a quarter of referrals were from specialties that POPS does not accept and some requested emergency reviews not appropriate for this service. The first improvement cycle effectively decreased the number of inappropriate or unsafe referrals according to clinician feedback. With the second cycle we hope to improve the quality and content of referrals as we introduce our referral form.

Conclusion - The new system improved the suitability and quality of referrals to POPS. By reducing inappropriate referrals to POPS, eligible patients could be seen by the right service in a timely manner, improving outcomes. We saw that a proforma is an effective way to improve referral content, and that an online form is useful in making an accessible referral process.

Introduction
Timely administration of medication for people living with Parkinson’s Disease (PwP) is critical. Missed or delayed Parkinson’s Disease (PD) medication can lead to motor complications, swallow impairment, and in some cases a neuroleptic malignant type syndrome. This can lead to morbidity and mortality and longer hospital stays. Our local policy on the nil by mouth (NBM) guidance for PwP is available on the intranet. We wanted to audit knowledge of, and adherence to this policy.

Method
An audit tool was used to collect responses from nursing and medical staff in the Clyde sector, including Royal Alexandra Hospital, Inverclyde Royal Hospital and Vale of Leven Hospital. Paper copies and QR code linking to the questionnaire were distributed across the wards between November 2022 to January 2023.

Results
A total of 124 responses were obtained, where 84 were prescribers. The responses showed some pre-existing understanding on the NBM policy for PwP, with 77% agreeing that Rotigotine patches should be considered if the oral or enteral feeding route is unavailable. 67% also knew the frequency for Rotigotine patches to be changed. Of the responses, only 52 (50%) have seen the trust’s NBM policy. Prescribers were also asked on how to calculate the dose for Rotigotine patches, 37 (52%) knew of the online calculator or referring to a guideline, with the remaining unsure or leaving the question unanswered. 41 (33%) knew the location of the emergency stock for PD meds.

Conclusion
Our study has shown a gap in the awareness of the NBM trust policy for PwP and highlights the need for more staff education. Educating medical staff at their weekly teaching and signposting them to the local guidance will be a starting point for our intervention. For the wider hospital staff, further training will be provided during PD awareness week.
 

The National Mortality Case Record Review Programme commissioned in 2016 aimed to improve the learning from deaths process. As part of this aim, several reports were published, which identified barriers in implementing the mortality review process. Mortality and Morbidity (M&M) meetings can be an important mechanism for removing these barriers, and while have been in place for a long time in surgical specialties, are only recently becoming more common in medical specialties. We have developed an innovative M&M meeting in our geriatric department to integrate Mortality case reviews with teaching and QI development.

Methods: We created a standardised mortality data collection proforma, using the (SJR) framework as a template. During the development, feedback was obtained from consultants and juniors. Data was then collected using the proforma by trainees, and all mortality cases were then reviewed with consultant supervision, and specific cases were chosen for their educational benefit or requiring areas of improvement. Cases were then presented at the meeting. At the end of the meetings, an action plan was then created in collaboration with the consultant and juniors in the meeting to create a teaching plan or develop a QI project to help improve service.

Results: From feedback gained, the M&M was well received, and has already helped improve training and delivery of end of life care and recognising the dying patient. There were several difficulties identified during the process such as incomplete medical records, time & lack of engagement from other team members due to work pressures.

Conclusion: Mortality meetings are an essential part of junior doctor training and hospital clinical governance, often times underutilised. They can support quality improvement and professional learning, especially when facilitated by a standardised mortality review process.

Introduction: Neck of femur fractures (NOFFs) are a clinically significant diagnosis, with 10% of patients dying within one month of diagnosis [1]. There is a strong association between earlier surgery and improvement in postoperative outcomes [2]. Taking anticoagulation can cause delays in patients being operated on. At Homerton University Hospital (HUH), no previous guideline existed to aid specifically in the management of patients with NOFFs on anticoagulation. We created a guideline in order to reduce delays to theatre, in keeping with national guidance (<36 hours to operation). Methods: We audited all patients in 2020 admitted to HUH with NOFFs taking anticoagulation. A guideline was then created, reflecting new national guidance [3] on the management of anticoagulation pre-operatively for NOFF patients. Three PDSA cycles were completed, with repeat audit cycles following dissemination and teaching of guideline to relevant clinical groups. Results: Following implementation of our guideline, 56% of patients had surgery within 36 hours of admission, compared to 25% previously. Advice being given to the admitting team regarding timing of the operation was more consistent, and the admitting team needed to ask for advice less often. There was an overall increase in consistency of management. Conclusions: Ensuring NOFFs are operated on promptly reduces the risk of co-morbidity and mortality [2]. There are often incorrect delays to theatre following anticoagulation administration due to perceived risk of bleeding. We created and implemented a new guideline, which successfully reduced time taken for patients on anticoagulation to be taken to theatre for operation. References: [1] NICE. ‘Hip Fracture: Management’. Clinical guideline. Published: 22 June 2011. Accessed at: nice.org.uk/guidance/cg124 [2] Seong YJ, Shin WC, Moon NH, Suh KT. Timing of Hip-fracture Surgery in Elderly Patients. Hip Pelvis. 2020;32(1):11-16. doi:10.5371/hp.2020.32.1.11 [3] Griffiths, R., Babu, S., Dixon, P., Freeman, N., Hurford, D., Kelleher, E., Moppett, I., Ray, ), Guideline for the management of hip fractures 2020. Anaesthesia, 76: 225-237.

INTRODUCTION Falls have significant morbidity and mortality in Nursing Home (NH) residents. By improving education to NH staff we aim to reduce 999 calls and associated adverse outcomes. . NH residents are more likely to fall than people living in the community and are more at risk of further falls as interventions and risk factor modification is more difficult.

METHODS Phase 1 - Ambulance calls, where a vehicle attended the scene, between 01/01/2020-28/02/2022 from NH in Swansea Bay University Health Board (SBUHB) concerning Falls/?Falls (Haemorrhage/lacerations, Unconscious/fainting, traumatic injuries, sick person, convulsions/fitting) were analysed and survey was sent out to all NH. Phase 2 - Education was provided about CWTCH (hug in Welsh) and staff were surveyed post intervention Can you move them, Will it harm them? - new neck/back pain, anticoagulation, Treat them – analgesia, wound-care, Cup of Tea – can eat & drink , Help – when contact 999.

RESULTS Phase 1 – Between 01/01/2020-28/02/2022 4907 calls, 866 were falls (17.65%) and 1032 ?Falls (21.07%), 60.49% conveyed to hospital. 47% of NH do not have falls guidelines and 100% patients are Nil by Mouth and 88.24% are not moved. Emergency services were contacted 88.24%. Phase 2 - Education was delivered to all NH in Swansea (122 staff). Feedback showed 100% feel more confident in giving food and drink, moving patients with 90.98% less likely to contact 999 and 75.40% not having previous training with 96.72 % more confident in giving analgesia.

CONCLUSIONS Falls remain a significant burden and a rapid service would improve care with conveyance reduction to 53.1% post education (60.55% pre-education). Future directions include offering this education to NH in Neath/Port Talbot. From March 2022, we offer same-day assessment for NH residents (and others) from primary care and ambulances and are developing a PRN analgesia pathway e.g.PENTHROX

Introduction: Dehydration is a major contributing factor to morbidity and mortality in elderly patients, as they are at greater risk and more vulnerable to the consequences of inadequate fluid intake. Care of the Elderly (COE) wards are set up to meet the specific care needs of elderly patients, however, these care needs are not consistently met on medical outlier wards at NUH. This project aimed to improve hydration-related patient care on outlier wards using a sustainable intervention by increasing average daily fluid intake (ADFI) by 50% and patients with drinks within an arm's reach by 50%. Methods: Cycle 1: Hydration parameters (ADFI, glasses within reach, drinks offered, glasses filled) were audited for patients on two COE wards (n=25) and four outlier wards (n=19). Cycle 2: Reminder to offer patients a drink added to outlier patients' ward round entries and nurses verbally informed over 1 week (n=14). Cycle 3: 'Think Drink' poster placed at outlier patients' bedsides as a visual reminder and nurses verbally informed over 1 week (n=15). Results: Cycle 1: ADFI was 774mls greater on COE than outlier wards, 299% more glasses within reach, 62% more drinks offered, 78% more glasses filled. Cycle 2: 52% increase in ADFI (258mls), 104% more drinks within reach, 11% more drinks offered; 15% less glasses filled. Cycle 3: further 8% increase in ADFI (62mls), 87% more glasses within reach, 4% more drinks offered, and 124% more glasses filled. Overall: 65% increase in ADFI, 280% more glasses within reach, 15% more drinks offered, and 90% more filled glasses. Conclusions: An important gap in care was identified between COE and outlier wards, leaving elderly outlier patients vulnerable to dehydration. 'Think Drink' poster acted as a successful visual reminder for staff and visitors demonstrated by an increase in all hydration parameters, improving hydration-related patient care.

Introduction

Dysphagia affects a large proportion of patients in hospitals and the community. Poor management of dysphagia results in aspiration pneumonia, malnutrition, and poor quality of life. Management, as recommended by Speech and Language Therapists (SALT), with the strongest evidence base for reducing aspiration pneumonias, is diet modification such as thickened fluids (Rosenvinge S, Starke I. Age and Ageing. 2005;34(6):587-593). Safe management of dysphagia is important discharge, as such this study focused on patients being discharged with fluid thickeners.

Method

We assessed current rates fluid thickeners being correctly prescribed on discharge medications by analysing data sets of patients discharged by the inpatient SALT from January to February 2022; including rejected referrals, deceased patients and discharges without fluid thickeners (n=223). 26 data sets were further analysed, after applying inclusion and exclusion criteria. Data was collected on whether thickeners were prescribed as inpatient, on discharge alongside analysis of nursing notes and SALT plans.

Results

Overall, 69.2% (n=18) of patients had thickeners correctly prescribed on discharge. Of the remaining 30.7% (n=8) without thickeners prescribed on discharge, 87.5% (n=7) of these were also not prescribed as inpatient. Whereas only 9.01% (n=1) of cases had thickeners prescribed inpatient but missed on discharge. 92.31% (n=24) of nursing notes included SALT recommendations and noted that thickeners were being given.

Conclusion

Results highlighted that the burden of administrating thickeners in hospital fell upon the nursing staff who used a communal stock of fluid thickener, regardless of inpatient prescription. A recommendation put forward to doctors, and to be included in SALT plans is to prescribe thickeners on inpatient charts, to reduce chances of missed prescriptions on discharge. Similarly, including SALT recommendations in discharge summaries will aid correct prescribing for patients in their future admissions. Further education and dissemination of the importance of dysphagia management will also be beneficial

Introduction 

An increasing number of older people living with frailty are undergoing surgery. The Centre for Perioperative Care (CPOC) published guidelines in 2021 to improve the care of this patient group through the perioperative pathway. Whilst significant progress has been made in Cardiff and Vale in improving unscheduled surgical care for older people, there remains a dearth of services for patients undergoing elective procedures. 

Method 

A Perioperative Frailty team was formed to deliver a service based on Comprehensive Geriatric Assessment principles, for older people undergoing elective surgery. Support was sought from Health Education and Improvement Wales for a Leadership Fellow to help implement a pilot service, with additional funding from the Bevan Commission for nursing secondments.  

Results

A standard operating procedure and uniform patient assessment proforma were compiled.  Digital Transformation software was developed to enable clinical frailty scale (CFS) scores to be recorded electronically in the preoperative assessment clinic. This enabled identification of patients who are aged ≥65 with CSF ≥ 5, streamlining referrals, allowing an operational service and evaluating the impact of Perioperative care for Older Patients in the elective setting.   The team have collaborated with perioperative specialties, therapies and the third sector to increase awareness of the service.

Conclusion    

Planning a new hospital service presents multiple opportunities as well as many, sometimes unforeseen, challenges. Our recommendations for colleagues designing new pathways for older people are: consider the strategic plan of your organisation together with the vision of the department to guide service design and selection of outcome measurements; ensure baseline data for the pre-intervention service is available and of high quality; compile a clear project plan with realistic and achievable time frames; explore stakeholder engagement; and most critically, to continually measure and evaluate any new or modified service from the outset. 

Introduction:

Suprapubic catheter (SPC) insertion is recognised as an alternative to urethral catheterisation to enable urinary drainage or continence control. This audit aims to establish the 1 and 2 year mortality associated with SPC insertion and to identify factors that may be linked with mortality.

Methods:

Data were collected for demographics, medical co-morbidities, indication for procedure and mortality from 1st February 2018 to 1st February 2020 across three NHS trusts. Multivariate regression analysis was undertaken to assess correlation between mortality and collected data.

Results:

48, 12 and 8 (total 68) SPC insertions were identified at the respective trusts. Two patients were excluded owing to a lack of mortality and cognitive data. Total mortality was 10.4% (7/67 patients) at 1 year and 16.4% (11/67 patients) at 2 years. Two-year mortality for those with a clinical frailty score (CFS) ≥3 and <3 was 21% (6/28) and 13% (5/39), p>0.05. Two-year mortality in those aged over and under 71 was 21.6% and 10.3% respectively. Other collected risk factors were not associated with increased mortality.

Conclusion:

Our study has demonstrated increased mortality rates in both the moderately to severely frail population and in elderly patients. These results have triggered the entry of SPC insertion onto the Model Hospital dashboard which states a national 1 year mortality rate of 15.4%. Clinicians should continue to be judicious when considering patients for this procedure.