Discharge

Background: Patients triaged as routine, discharged home from Intermediate Care Units (ICUs) in areas of West Sussex wait  approximately 4 weeks or more until rehabilitation continues by the Community Therapy Team (CTT).

Introduction NHS England (2023a) and NHS England (2023b) call for minimal delays, effective coordination processes and sharing of information for timely rehabilitation in intermediate care settings. Local patient feedback indicated poor patient satisfaction and increased clinicians anxiety regarding risk of deterioration due to long waits (Lewis A., 2018).

Aim To improve average wait times for routine ICU patients’ discharge, for ongoing community therapy input, to within 1 week by July 2024, while maintaining patient safety and improving patient satisfaction.

Methodology: Quality improvement methodology, using stakeholder engagement was used to determine the cause for long wait times for home therapy. PDSA cycles were engaged to determine if improvements could be made without a loss of quality of care, or impacting patient safety, while improving patient experience. These involved formal communication channels between teams and using a therapy assistant for an initial home assessment where assessments had already been undertaken by registered therapists on the ICUs. Patient satisfaction surveys were undertaken to understand the experience of transition home.

Results: Baseline data indicated that waiting time for home therapy varied between 18 - 59 days, from discharge. After the initial PDSA cycle, waiting time reduced to between 4 - 10 days, and after the second cycle waits reduced further to between 3 - 7 days. Patients’ satisfaction improved significantly with shorter waiting times for therapy once home.

Conclusion: Therapy assistant initial visits at home reduced waiting times to within a week, and patients’ satisfaction improved with shorter waiting times. Patient safety was not compromised as there were clear protocols for appropriate escalations for unregistered staff.

Background: This improvement project was done within the Geriatrics/ Stroke department and aims to meet the following adapted standards: all discharged patients must leave with the original DNACPR document, and clear documentation of their DNACPR and review status in the immediate discharge letter to their Primary care provider.

Local problem: Firstly, not all discharged patients leave with the original DNACPR document and secondly, their DNACPR status was not communicated to their Primary care provider which highlights a communication gap which exists between secondary and primary care.

Methods: Retrospective data on frail and critically ill patients who had a DNACPR form within the last twenty days were collected from medical records. The review showed whether the original document was given to the patient upon discharge and if information was communicated to the Primary care provider within the immediate discharge letter.

Interventions: To implement changes, email communications were disseminated to the Geriatrics/ Stroke team, posters displayed in prominent locations around the Geriatric/ Stroke wards, a message prompt was added to the clinical progress section of the electronic immediate discharge letter and education was given to the ward clerks to ensure the patient’s original DNACPR document is given to them on discharge and a copy kept on their paper medical case notes.

Results: In twenty days, a total of twenty-eight patients were discharged from the respective wards, of which nine met the criteria. Only two, were discharged with the original DNACPR form and none of the DNACPR decisions were communicated to Primary Care.

Conclusion: This project is ongoing and aims to collect quantitative data biweekly. At the end of the cycle, we aim to achieve 40% improvement in DNACPR status communication to primary care and 30% increase in patients being discharged with the original document by October 2024.

Introduction: Discharge summaries (DS) for older patients can be more complex due to an increasing life-expectancy and multiple co-morbidities. However, this is not always reflected in the quality of DS produced. It is generally agreed that good quality DS should reduce readmission and improve patient care after discharge.

Aims: Identify areas of weakness in Discharge summary V4 a on an elderly care ward at Salford Royal Hospital (SRFT) using a pre-established assessment and scoring tool. Secondary aims were to use interventions an educational session, poster (S.M.I.L.E) and acronym expansions to improve DS quality.

Methods: This prospective QIP was a three-cycle project assessing DS collected over a 2-week periods on an elderly care ward at SRFT. Phase one (n=8 DS) assessed DS any intervention. Then intervention one (a poster and educational session) was implemented and assessed in phase two (n=8), whilst phase 3 (n=12) assessed a second intervention (acronym expansions).

Results: Initial areas for improvement including safety-netting (complete in 5/8), indications for medications (started 4/6, stopped 4/5 and changed 1/3), lay language (done poorly or not at all in 3/8) and follow up information. After intervention one 7/8 DS had “good” lay language and indications for stopping/starting medications were included in 100% of DS. Phase three demonstrated indications for medication changes were not maintained however results in other areas remained largely the same.

Conclusion: Discharge summaries for aging patients are complex and further research should look at patient and relative perspectives to ascertain a patient centred approach to improving discharge summaries.

Introduction

Malnutrition is common in patients with hip fractures. Early post-operative ONS (oral nutritional supplements) have been shown to reduce the length of stay in hospital and improve post-operative outcomes. The aim of this audit is to determine the number of people within the Royal Victoria Hospital Fracture Unit with NOF (neck of femur) fractures who are receiving ONS; it also determined the reasons for doses missed. Additionally, it covers if baseline refeeding bloods were done as per Trust Guidelines.

Method

A two cycle audit was completed on the use of ONS in patients with NOF fractures in the Royal Victoria Hospital Fracture Unit. Data from 29 patients in the first audit and 30 patients in the re-audit was analysed. The amount of people who had ONS prescribed, the amount of doses they received, and the reasons doses were missed were recorded. The data was collected, analysed, and the following interventions were put in place. Reviewing ONS compliance with each patient in the standard day 1 and day 4 post-operative reviews commenced. The medical team were informed that baseline refeeding bloods (bone profile and magnesium) should be done on admission.

Results

From the first cycle to the second cycle, the number of patients getting refeeding bloods within 3 days of admission increased from 20.1% to 56.7%. The proportion of patients who missed ≤ 25% of doses of ONS increased from 38% to 76%. The number of doses missed per patient due to refusal dropped from 1.1 to 0.6.

Conclusion

To conclude, ONS have been proven to help reduce post-operative complications and improve rehabilitation. Integration of ONS as a part of the post-op review process should be highly encouraged. This gives a standardised way for the department to ensure compliance with the guidelines.

Introduction:

Older patients attending the Emergency Department (ED) and discharged home are at higher risk of adverse outcomes. Geriatric Ambulatory ED services were developed with the aim to deliver goal-directed care of older patients from ED using onward referral to Community Providers.

Method:

A retrospective review was undertaken from 13th January 2022 to 23rd December 2022 in older patients discharged from the ED following a targeted geriatric assessment and recommended community follow-up interventions. Demographic information, functional ability, hospital utilisation and mortality (up to one year), and any post-visit fragility fractures were reviewed. Data collection included identification of osteoporosis or osteopenia during or following the index ED visit.

Results:

108 patients were assessed, of whom, 74% were female, average age 76 years, range 61-93 years. 65% of patients were CFS scored, 9% were CFS 6 or 7, 15% CFS 4 or 5 and 41% CFS 1-3. GP review was advised for 76% of patients and 61% attended and therapy interventions were recommended for 9.3%, of whom, 3% attended. The majority presented with falls (82%) and half of those who fell, sustained a fracture. Osteoporosis or osteopenia was newly identified in 30% but in 44% of patients bone health remained unevaluated and only 8% had newly initiated anti-resorptive and 9% existing treatment. 4% experienced fragility fracture following their ED visit. Uptake was low for therapy (30%) and nursing interventions (14%). Following the index ED visit, 7% patients attended ED within 7-days, and 5% admitted to hospital within 30-days. 35% of patients re-attended ED and 22% were hospitalised within one year. One year mortality was 5%.

Conclusion:

ED targeted geriatric assessment can identify patients with falls and fragility fractures but better collaboration and communication between primary and secondary care is needed. Recommended bone health assessment occurred in a relatively small proportion of patients.

Introduction: The terminology surrounding manual-handling equipment and discharge planning is rarely taught in medical school. Yet, it is crucial for medical staff, particularly those working on Care of the Elderly (COTE) wards, to comprehend these terms to accurately assess a patient's function and optimise discharge planning.

Methods: A 17-question survey was distributed to establish the baseline knowledge of medical staff in a district general hospital, with the aim of using PDSA (plan, do, study, act) cycles for improvement as needed. Following preliminary data analysis, a lunchtime hospital teaching session was designed to educate individuals on these key terms and equipment. Ten clinicians attended and took part in a mentimeter quiz reassessing knowledge post-teaching.

Results: Seventeen participants, ranging from physician associates and junior doctors to consultants, completed the initial survey anonymously. Knowledge varied widely, with scores ranging from 15% to 91%. All participants accurately identified a Zimmer frame, 15 (88%) correctly labelled a PAT slide and 13 (76%) a hoist. Reassuringly, all knew that the acronym “POC” stood for Package of Care. Poorly recognised equipment included turn discs, standing hoists and hover jacks. Furthermore, the term “reablement” and the healthboard-specific “complex needs booklet” lacked clear definitions. While many participants could define fast track discharge, they could not distinguish between the two types. The average score per question increased from 53% in the pre-teaching survey to 59% post-teaching, however this was not statistically significant (P=0.57).

Conclusions: Although medical staff were familiar with certain equipment, they lacked understanding of more specialist aspects of discharge planning and less commonly used equipment. Unfortunately, these results did not significantly change post-teaching, likely due to low attendance; however, we are hopeful that the survey distribution and teaching will spark discussion throughout the hospital. We have now adapted the teaching content into posters for the next PDSA cycle. 

Introduction                                                                                                                                                                        High number of clinically optimised patients in a DGH were having daily clinical input. RAAC clinical incident resulted in movement of clinically optimised patients from the district general hospital to a community hospital increasing the community bed base from 32 to 72. This gave the opportunity to review how these patients were managed.             

Method                                                                                                                                                                                    It was recognised that a daily medical ward round for clinically optimised patients was neither necessary or optimal and potentially perpetuated the impression that patients required in hospital care. National guidance supports delegation of daily review to other members of the Multidisciplinary Team. All clinically optimised were planned to be seen once a week on a medical ward round. All patients were discussed on the daily multidisciplinary board round and if needed were changed on the board to not clinically optimised which prompted review. Nurses could also ask for review outside of the board round.                                                                                                                                                                             

Results                                                                                                                                                                            During four weeks period one third ( 24/72 ) of patients needed review outside of the weekly planned review. Of these 79.2% required only one review. Junior doctors reported that they previously spent 5-15 minutes per day per clinically optimised patient. Therefore time saving of 16-48 hours per week was estimated. Balancing measures of falls, mortality, pressure sores and complaints showed no change in the four months after implementation of the change. Patients, family and staff qualitative feed back was gathered. Stage two of the project offered clinically optimised patients a ' What Matters to Me' meeting with their family utilising the time saved by reduced ward rounds to improve communication, medication review and future care planning.                                                                                            Conclusion                                                                                                                                                                          Data suggested no adverse impact of change in practice. Staff were redeployed to the front door frailty team rather than community hospital to improve access to Comprehensive Geriatric Assessment at admission in the Emergency Department and Acute Frailty Unit.

Introduction

Information-sharing between primary and secondary care is vital for patient safety and reducing duplication. The Electronic Discharge Summary (EDS) enables this but is often incomplete due to time pressures and poor team continuity. Information from the Comprehensive Geriatric Assessment (CGA) by the Perioperative care of Older People undergoing Surgery (POPS) team is often omitted, leading to queries from primary care colleagues and duplication of work on readmission to hospital.

Methods

Eight core CGA components were determined for inclusion in the EDS. Twenty EDS were reviewed to for each PDSA cycle to assess compliance. Various strategies were trialled to increase compliance including junior doctor education (attendance at induction plus separate teaching), a checklist poster, the POPS team directly entering information into the EDS and a separate CGA summary.

Results

Baseline data demonstrated poor compliance with core CGA components (mean 25%, range 0-62.5%). PDSA 1 demonstrated improvement after junior doctor education and introduction of a checklist poster (mean 35%, range 12.5-87.5%). Mean compliance increased to 53% during PDSA 2 with the POPS team directly entering information into the EDS, but with continued wide variation (range 12.5 – 100%). The introduction of a POPS CGA summary to complement the EDS in PDSA 3 increased compliance with reduced variation in practice (mean 99%, range 87.5-100%).

Conclusions

Sharing information gleaned from a CGA was marginally improved with education, but is challenging due to the rotational nature of staff completing the EDS. The improvement seen with the POPS team entering EDS information was limited by the lack of 7-day working and the ‘locking’ of the completed EDS by the parent team. A separate CGA summary markedly improves information-sharing, with reduced variation in practice. This has benefitted primary and secondary care colleagues, as well as the POPS team when patients are readmitted or attend clinic.

The Psychological Impact of Hospital Discharge on the Older Person

Hussein Y ¹, Edwards S ², Patel HP ^2,3,4

¹ Undergraduate Medicine, Faculty of Medicine, University of Southampton, UK;       

² Department of Medicine for Older People, University Hospital Southampton NHS Foundation Trust, UK; ³Academic Geriatric Medicine, University of Southampton, UK; ⁴NIHR Southampton Biomedical Research Centre, University of Southampton & University Hospital Southampton NHS Foundation Trust, UK

Background

The number of older people at risk of health-related morbidity is growing at an unprecedented rate. Older people often require hospitalisation but prolonged length of stay and deconditioning in the acute setting is associated with multiple adverse outcomes. On average, 35% of older people do not recover functionally after hospital discharge. Less is known on the psychological impact and coping mechanisms after hospital discharge for vulnerable older people. Our aim was to explore factors signalling psychological vulnerability in older patients post-discharge to inform better discharge planning.

Methods

A systematic search for studies reporting poor discharge outcomes in older people were performed in the databases Medline, CINAHL, PsycInfo between 2010-2022. The search terms were ’older patients >65 year’, ‘post-discharge’, ’psychological distress’, ’loneliness’, ‘anxiety’, ‘depression’, and ‘length of hospital stay’. Exclusion criteria included COVID-19 disease, dementia (+/- severe cognitive impairment), individuals aged <65 and those under palliative care services.

Results

1,666 records were identified of which 878 were excluded as they were outside of our date limits or were not in English Language. 681 were excluded after application of exclusion criteria and 699 were excluded because of insufficient details. 31 duplicates were removed leaving 38 articles that were assessed for eligibility. 7 of these reports were found suitable, comprising of 1,131 patients. Three highly relevant themes identified relating to post-discharge outcomes across all studies were social isolation, lack of support, depression, apathy and fear, which led to further psychological distress. Older patients with tendency toward depressive symptoms had an increase likelihood of death.

Conclusion

It appears discharge processes fail to address psychological factors that permit successful transition from hospital. Pre-discharge screening of psychological symptoms and coping ability may assist in identifying older patients who are at risk of mental as well as subsequent physical deterioration. Better knowledge of positive and negative predictors of a successful transition from hospital to home would enable more holistic, effective, and inclusive discharge planning processes for older people.

Introduction:

Care home residents are increasingly presenting to hospitals. In October 2022, a frailty team was formed in our district general hospital, consisting of two SHOs, one SpR and one consultant, with support from pre-existing care home ANP and community resource team (CRT). Focusing on patients presenting to the Emergency Department, their aims were early identification of care home residents in order to optimise their care by facilitating discharge, tackling polypharmacy and seizing opportunities for advanced care planning.

Method:

Care home residents were highlighted on the ED clinical system, using a unique icon, and reviewed by the frailty team. Anonymised patient statistics were logged into a bespoke e-database. This generated a dashboard of graphs showing trends in outcomes. The statistics from the first 8 months (3/10/22 to 5/6/23) were utilised to show patient demographics, number of reviews and rates of discharge.

Results:

297 care home residents were reviewed. 83.8% of these patients had a Rockwood Clinical Frailty Score of ≥ 7. Delirium was present in 91 (30.6%) patients. 121 (40.7%) had at least 1 medication stopped. 165 (55.6%) were discharged after frailty review. Do not resuscitate forms were completed for 208 (70.0%) patients. Advanced Care Planning was discussed with 138 (46.5%) patients and 6 (2.0%) patients were not for re-admission. End of life care was commenced for 17 (5.7%) patients.

Conclusion:

It is clear that patients attending the Emergency Department would benefit from an early comprehensive geriatric assessment. The benefits this has provided in one North Wales DGH are significant and have made strides in reducing unnecessary admissions, reducing polypharmacy and providing holistic, interdisciplinary and patient centred care including advanced care planning. Whilst the Emergency Department is not an ideal environment for this, the team have demonstrated the benefits to this model.