CGA in acute settings

Introduction: Osteoporosis causes significant deterioration of bone health predisposing individuals to an increased risk of fractures. Hip fractures in particular lead to increased mortality, morbidity and substantial economic burden on the healthcare system. Early identification of high-risk individuals is crucial to improve patient-related outcomes and significantly reduce the burden on our healthcare system. The objective of this quality improvement project (QIP) is to promote osteoporosis risk assessment in the frailty unit at North Manchester General Hospital (NMGH), by introducing a Comprehensive Geriatric Assessment (CGA) inclusive of a bone health risk evaluation. Methods: CGA, including a formal bone health assessment (as per NICE guidelines April 2023) was implemented in our frailty unit. This QIP was carried out in two cycles. Baseline data was collected (N = 33) retrospectively in January 2023 before CGA implementation followed by data collection in May 2023, to evaluate CGA with bone health assessment inclusion as an intervention (N=31). At the end of cycle one the results were presented to staff including education on CGA and bone health. Cycle two, conducted in June 2024 assessed compliance (N=30). Results: Bone health assessment compliance improved from 15% at baseline to 55% after cycle one and 83% after cycle two. When evaluated for inclusion of a bone health treatment plan, the baseline value was 31% which improved to 84% and 90% in cycles one and two, respectively. Conclusion: Implementing CGA with the bone health assessment standardised interventions to improve patient’s bone health admitted to the frailty unit at NMGH. CGA also helped identify people at risk of fractures and to initiate prompt management. This QIP helped our frailty unit to adhere to NICE guidance, thereby improving the quality of care offered at NMGH.

Introduction

The Older Persons Assessment and Liaison team at North Manchester General Hospital (NMGH) reviews geriatric patients using a Comprehensive Geriatric Assessment (CGA), as directed by the British Geriatric Society. The Anticholinergic Burden (ACB) score is an integral part of the CGA however it is often overlooked. ACB is the cumulative effect of taking one or more drugs used to block Acetylcholine. A greater ACB score increases the risk of developing adverse drug reactions such as; falls and urinary retention. As such, it is integral that we work to reduce patient ACB scores during hospital admissions.

Aim

To reduce the ACB score of geriatric patients at NMGH.

Method

Several months of retrospective data for 50 patients was analysed. We then carried out teaching on the importance of ACB documentation and its’ implementation. ACB scores were compared before and after this teaching session.

Results

Before the teaching session, 60% of patients had their ACB score calculated, however only 18% had an improvement in their score on discharge. After the teaching session 75% of patients had their ACB score calculated and 32% had an improvement in their score on discharge.

Conclusion

Although the teaching session was a successful intervention, as there has been a reduction in the ACB score of frail patients, there is room for improvement. We are hoping to integrate ACB score calculation into the computer software used throughout the hospital to break down the barriers that clinicians currently face in using it.

Background

The Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary tool, designed to promote holistic care of elderly patients and provide a framework for intervention. There is evidence that the CGA reduces mortality and slows progression of frailty. Performing such interventions in the acute setting can be complex and time-consuming.

Introduction

The Older Person’s Assessment Unit (OPAU) at Weston General Hospital allows early identification of frailty and prompt intervention. We aimed to promote elements of the CGA by providing a tool for utilisation throughout the patient’s admission to coordinate patient care.

Methods

This was a prospective pre-post intervention study on OPAU. We reviewed medical records in a 5-day period analysing documentation of elements of the CGA. The primary intervention was introduction of a ward-round proforma prompting delirium screening. Following analysis and re-evaluation, a an updated proforma with an additional bone-health prompt was circulated. The completion of proformas was re-assessed.

Results

Baseline data of 20 patients showed that common presenting complaints were falls and confusion. Only 14% of those who presented with a fall had a documented bone-health screen. 0% of patients with confusion had a delirium screen. After cycle 1, 0% had bone-health screening and 20% had delirium screening. Following cycle 2, 89% of patients who had a fall had completed bone-health screening.

Conclusion

Implementation of a CGA-orientated ward-round proforma encourages consistent documentation. It demonstrated successful increased uptake of delirium and bone-health screening. The future aim is to introduce a full CGA proforma that encourages opportunistic assessment by all members of the multi-disciplinary team.

Introduction:

Chronic limb-threatening ischemia (CLTI) is defined by presence of peripheral artery disease, rest pain, and/or gangrene or ulceration.1 Management of CLTI often involves a major amputation which has a 30-day in-hospital mortality of 6.6%. Despite improvements in secondary risk management, 5-year mortality remains high.1 Understanding how comorbidity affects amputation survival may help support patient optimisation and shared decision-making.

Methods:

This audit assessed the outcomes of patients who were reviewed by the POPS team using a comprehensive geriatric assessment (CGA) before undergoing a major lower limb amputation. We retrospectively analysed electronic records from 60 patients with CLTI who were admitted in an emergency setting, reviewed by the POPS team, and underwent a major lower limb amputation during 2022. The primary outcome measure was death following surgery. Data was collected from the patient records and analysed using the Chi square test.

Results:

In this group of 60 patients the 30-day mortality was 5% (3 patients) and 1-year mortality 43% (26 patients), with the average age at time of death being 77 years. Age (p=0.022) and co-morbidity (p = 0.021) were the strongest prognostic factors for mortality. Other factors like clinical frailty score (CFS), albumin concentration and length of hospital stay showed non-significant correlations with mortality in patients who underwent lower limb amputation.

Conclusion:

This study highlighted prognostic factors that could enable doctors to identify high-risk patients who may benefit from optimisation and detailed shared decision-making prior to undergoing a major lower limb amputation. As mortality is not necessarily modifiable, even in the context of a CGA in this group, it also highlights the need for advanced care planning before discharge.

References 1. Waton S, Johal A, Birmpili P, et al. National Vascular Registry: 2022 Annual Report. London: The Royal College of Surgeons of England.

Introduction:

Frailty is the concept of increasing vulnerability to minor stressors in the context of a reduction in physiological reserves (Clegg et Al. The Lancet 2013, Volume 381, pages 752-762). It affects 10% of people presenting to Emergency departments (ED) and around 30% of inpatients in acute medical units (NHS England and NHS Improvements. 2019). Implementing a CGA is known to result in a significant increase in your likelihood of being alive and in your own home at 6 months (Ellis et Al. BMJ 2013).
 

Aims:

To implement an ED in reach frailty service with the goal of performing a CGA at the earliest opportunity.
 

Methods:

We undertook a 3 week pilot with a small team comprising a consultant, frailty ACP, SHO and geriatric registrar. The team were based in ED and worked alongside the existing ED navigator team and in conjunction with various community teams. Data was collected assessing completion of the usual domains within the CGA and discharge data.

Results:

62 patients were seen in total. Mean age was 82.4 years with a mean CFS of 5. Each patient received a CGA. 9/62 (15%) of patients were discharged on the same day. 15/53 (28%) were discharged within 72 hours of admission. Other notable results include: 100% completion of 4AT and 70 medications de-prescribed. Feedback from patient and relatives in addition to ED and AMU doctors was extremely positive.
 

Conclusion:

We demonstrated that performing a CGA in ED resulted in higher numbers of patients being discharged on the same day or within 72 hours of admission. We were able to demonstrate a significant increase in assessment of delirium allowing earlier detection and a much higher rate of deprescribing with significant benefits for both patient and the trust.

Introduction:

Recent studies show the use of comprehensive geriatric assessment (CGA) in older patients with cancer can result in better quality of life, improved treatment tolerance and reduced hospital admissions, leading to international consensus that CGA should be routinely included in care. We have piloted an onco-geriatric MDT, consisting of oncologists, geriatricians and therapy input, alongside a rapid-access geriatrician-led onco-geriatric clinic

Method:

Referrals were invited from oncologists for older patients (>70) with a new diagnosis of cancer, with expected prognosis of more than 1 year, about whom they had concerns regarding their ability to undergo radical treatment due to co-morbidities, falls, cognitive impairment or social isolation. A CGA was completed prior to starting radical treatment in most cases. Performance status, Rockwood frailty score(RFS) and G8 score were calculated for all patients.

Results:

During the 24 week trial period, an MDT and clinic has run every week. A total of 32 patients have been discussed at MDT, with 22 seen in clinic, from cancer sites including colorectal, breast, urological and ovarian. Patient seen in clinic had an average RFS of 4.5 and G8 score of 13. All patients have seen a geriatrician, with most also seeing our physiotherapist. Interventions included medication review and rationalisation, anaemia review and treatment, referral to specialist memory and continence services, blood pressure optimisation and completion of a treatment escalation plan.

Conclusions:

Feedback from patients attending the clinic has been resoundingly positive, with 100% of patients rating their service experience as “good” or “very good” and praising the time to talk about their health as a whole. Follow up of clinic patients is in progress, identifying emergency admissions alongside treatment toxicities and complications within this group, as well as whether G8 is an appropriate screening tool for clinic review, to secure the long-term future of the service.

Introduction

Using a patient centred, valued based health care approach to reshape the acute frailty unit with the University Hospital of Wales. Our multi-disciplinary team provide our patients with a compressive geriatric assessment. The goal is to ensure our patients are treated in a timely, thorough manner to avoid deconditioning and hospital induced harm. We want our unit to be guided by the needs of our patient population.

Methods

A redesign of the service structure within the acute frailty unit was undertaken as a result a patient survey taken in 2021. The aim was to focus on concerns that patients had highlighted within their feedback; noting particular challenges with length of time spent within the accident and emergency department, access to analgesia and continence needs. We were able to note these concerns and work on redesigning our care model to focus on meeting these needs.

Results

Following these changes, we undertook focused interviews with patients. They speak positivity about their stay within our acute frailty unit; noting they feel listened to about their goals, they are kept up to date with their treatment plans and that the staff genuinely care. They continue to be concerned with regards to access to emergency ambulances and length of stay within the accident and emergency department.

Conclusion

Further significant changes have been made to the service structure following additional patient feedback. Our number of beds within the acute footprint of the hospital have been increased from 12 to 19. We hope that this, alongside a streamlining of the complete admissions process within the University Hospital of Wales, will allow us to continue to provide patient centred, valued based health care to our patient population.

Introduction

Many elderly patients presenting to ED with falls and suspected head injury are anticoagulated. The current National Institute for Health and Care Excellence (NICE) guideline recommends patients on anticoagulation should have a CT head scan within 8 hours of head injury. An updated guideline was drafted for consultation in November 2022. The indication for CT head scan has not changed for patients on anticoagulation. There is currently a lack of evidence to inform best practice in the management of anticoagulated older patients who present with falls and head injury.

The Older Persons Assessment Service (OPAS) in Morriston Hospital offers Comprehensive Geriatric Assessment to patients age >65 years who have presented with frailty syndromes, including falls. The aim of this study is to evaluate the risk of ICH in the elderly population presented to OPAS on anticoagulation following falls and suspected head injury.

Method

A retrospective study was conducted on consecutive patients who presented to OPAS from 1^st June 2020-18th May 2022. Data were collected on demographics, anticoagulant therapy, Rockwood Clinical Frailty Scale (CFS), Glasgow Coma Score (GCS) on presentation, evidence of external head injury and CT head findings.

Results

215 of 838 patients were on anticoagulation (median age 86(IQR: 81-90),56% Female).

The risk of ICH in patients presenting to OPAS who were on anticoagulation is 0.0186 (4/215, 95% CI 0.0051–0.0469); one patient’s CFS was 4(vulnerable) and three patients’ CFS were 5(mildly frail), all presented at their baseline GCS. Only one patient presented with evidence of external head injury.

Conclusion

The risk of ICH in elderly patients on anticoagulation presented to OPAS with falls is low. Those who had ICH were categorised as vulnerable and mildly frail. This study could support individualised decision-making for CT head scans, especially in moderate to severely frail patients following falls and head injury.