Education

Introduction: Comprehensive Geriatric Assessment (CGA) improves outcomes for frail older adults in acute hospitals. Patients aged 75 and over admitted into the Emergency Department (ED) at the QEUH will automatically generate a “frailty icon” on their electronic record. The number of frail people accessing emergency care is increasing. This Healthcare Improvement Scotland (HIS) frailty tool prompts staff to assess for frailty and refer to the local Frailty Pathway if appropriate. We designed a multidisciplinary quality improvement project (QIP) to increase completion of the frailty icon and the number of referrals to the frailty service from the ED.

Methods: Both medical and nursing staff in the ED were targeted for intervention. Weekly data was collected on the percentage of patients aged 75 and above who were discharged from the ED with a “frailty icon” completed over a 3-month period. Our main intervention was to hold a frailty awareness month. This involved multiple sub-interventions such as; announcements at handovers, e-mails, word-of-mouth, and posters.

Results: The weekly percentage of completed “frailty icons” increased from 28% 2 weeks pre-intervention (n = 283) to 48% in 1 month (n = 258). A peak of 57% (n = 293) completed icons was achieved immediately after our intervention. These increases were then sustained for a further 6 weeks with a weekly average baseline of 45.2% completion (average n = 281). Increased “frailty icon” completion in the ED led to a 100% increase in referrals to the frailty pathway.

Conclusion: Increasing awareness of frailty amongst ED staff results in increased front door assessment for frailty, and subsequent referral to the frailty team. This allows for more patients to receive a CGA. Multidisciplinary QIPs utilise the skills of diverse staff groups to best achieve sustainable change.

Introduction

Physical activity (PA) and replete nutritional status are key to maintaining independence and improving frailty status among frail older adults. We aimed to evaluate the feasibility and acceptability of training volunteers to deliver a remote intervention, comprising exercise, behaviour change, and nutrition support, to older people with frailty after a hospital stay.

Methods

Volunteers were trained to deliver a 3-month, multimodal intervention to frail (Clinical Frailty Status ≥5) adults ≥65 years after hospital discharge, using telephone, or online support. Feasibility was assessed by determining the number of volunteers recruited, trained, and retained; participant recruitment; and intervention adherence. Interviews were conducted with 16 older adults, 1 carer, and 5 volunteers to explore intervention acceptability. Secondary outcomes included physical function, appetite, well-being, quality of life, anxiety and depression, self-efficacy, and PA. Outcomes were measured and compared at baseline, post-intervention, and follow-up (3-months). Interviews were transcribed verbatim and analysed using thematic analysis.

Results

Five volunteers (mean age 16, 3 female) completed training, and 3 (60%) were retained at the end of the study. Twenty-seven older adults (mean age 80 years, 15 female) signed up to the intervention (10 online;13 telephone). Seventeen completed the intervention. Participants attended 75% (IQR 38-92) online sessions, and 80% (IQR 68.5-94.5) telephone support. Self-reported total PA (p = .006), quality of life (p = .04), and appetite (p = .03) improved significantly post-intervention, with a non-significant decrease at follow-up. The intervention was safe and acceptable to volunteers, and older adults with frailty. Key barriers were lack of social support, and exercise discomfort. The online group was a positive vicarious experience, and telephone calls provided reassurance and monitoring to socially isolated older adults.

Conclusion

Volunteers can safely deliver a remote multimodal intervention for frail older adults discharged from hospital with training and support from a health practitioner.

Introduction: Simulation training is a valuable resource to teach clinical skills and mimic emergency settings. Human factors (HF) are non-technical skills that are affected by human attitudes and behaviours. Weaknesses in human factors can cause fatal medical errors. We wanted to assess if simulation can be used as a tool to improve these. We conducted two simulation training days for medical higher specialty trainees (HST) focusing on HF.

Methods: 20 HSTs participated in 10 simulated scenarios. Scenarios involved using a high-fidelity manikin and actors. The scenarios were a mixture of long and short cases, including both clinical and non-clinical scenarios with a HF focus. Pre- and post-session questionnaires were used to rate confidence levels in a series of specific HF. A 10-point Likert scale was used.

Results: The majority of participants had a firm understanding of the importance of human factors in healthcare, especially the importance of teamwork, compassion, communication and situational awareness. 70% of participants felt that human factors training may not be adequately considered in current training pathways due to limited formal exposure, limited time, and its importance being underestimated. There was an increase in confidence in: managing disagreements (31%), negative emotions (38%), prioritisation (28%), delegation (23%), teamwork (34%) and leadership skills (30%), dealing with uncertainty (29%), challenging hierarchy (27%), anticipation (31%). 100% felt simulation training helped to develop their attainment of human factor skills.

Conclusion: This form of simulation training was successful in improving confidence and understanding of human factors in healthcare and showcased the value of using high-fidelity training to realistically recreate the clinical environment. Going forward, this type of teaching could be integrated within the specialty training curriculum to formally improve skills in human factors and therefore improve patient outcomes and relationships between team members, thus contributing to a more positive working environment.

Introduction

16% of adults over the age of 75 years old have a diabetes diagnosis¹ and 1 in 6 hospital beds in the UK is occupied by someone with diabetes². Keeping diabetic patients safe during hospital stays is a priority, and in 2023 the Joint British Diabetes Societies (JBDS-IP) published guidance on managing Diabetes in Frail inpatients³. An audit at our hospital later that year found that 70% of Capillary Blood Glucose (CBG) testing was non-compliant with guidelines resulting in unnecessary patient intervention, use of staff time and consumption of non-recyclable resources. The main aim of our project was to improve compliance with these guidelines and establish potential time and cost saving resulting from this.

Method

Focus on medical education with teaching sessions, information cards for lanyards and prompt posters around the inpatient ward areas. Worked with electronic prescribing team to establish use of an order-set for CBG testing to allow medical team to accurately communicate with nursing colleagues.  In addition, engaged nursing staff via ward bulletins and observed CBG testing on ward.  

Results

There was a reduction in CBG frequency for all diabetic patients of 27.9%. We identified that those patients with diet-controlled diabetes were commonly over tested, and in this sub-group the number of CBG tests performed was reduced by 51.9%. Average time for CBG testing was 147 seconds with anticipated cost savings from staff time and equipment use.

Conclusions

The use of default four times a day CBG testing results in unnecessary intervention in our frail inpatients. Through education and use of electronic systems we can reduce these interventions based on national guidelines, but more work needs to be done. Reducing CBG testing reduces use of healthcare assistant time, costly non-recyclable materials and overall reduces unnecessary patient intervention.

References

1. NHS England (2023) Health Survey for England, 2021 Part 2 < https://digital.nhs.uk/data-and-information/publications/statistical/health-survey-for-england/2021-part-2/adult-health-diabetes#:~:text=Prevalence%20of%20doctor%2Ddiagnosed%20diabetes%2C%20by%20age%20and%20sex&text=Prevalence%20increased%20with%20age%2C%20from,adults%20aged%2075%20and%20over.> Accessed 8/11/24
2. Watts.E, Rayman. G (2018) Diabetes UK: Making Hospitals safe for people with diabetes. Available at < https://www.diabetes.org.uk/resources-s3/2018-12/Making%20Hospitals%20safe%20for%20people%20with%20diabetes_FINAL%20%28002%29.pd> Accessed 24/07/2024
3. JPDS-IP 2023: Inpatient care of the Frail Older Adult with Diabetes. Available at <JBDS_15_Inpatient_Care_of_the Frail_Older_Adult_with_Diabetes_with_QR_code_February_2023.pdf (abcd.care)>

Background & Objectives

Research suggests that specialized education for nurses decreases frailty and improves functionality in hospitalized older adults. This study explored the impact of a specialized geriatric education program on  mobilization rates for older adult patients in acute care in 5 hospitals.

Methods

A mixed methods approach with pre- and post- intervention questionnaires (Geriatric In-hospital Nursing Care Questionnaire (Ger-INCQ) and study specific knowledge assessment) was used to explore facilitators and challenges of caring for older adults, the knowledge base and experiences of staff, and the impact of providing specialized education. Acute care nursing staff participated in a 4-hour education intervention focusing on the Geriatric 5Ms (Mind, Mobility, Medications, Multi-complexity and Matters Most) and frailty prevention. Patient level data was collected through mobility audits (I-MOVE) and observation of shift handover communication.  Semi-structured interviews with staff were completed to explore the results of the questionnaires. 

Results

Registered nurses, licensed practical nurses and personal care attendants (N=64, Mean age=36.9, 87% female) who participated in the specialized training did not show significant change in their assessment scores. Patient (N=99, mean age=76.2, 54.5% female ) mobilization did not differ between phases of intervention (p=0.08), nor was there any significant change in reporting mobility at shift handover. Ger-INCQ indicated neutral responsibility for falls incidents and retention of patient mobility, with interviews (n=26) revealing that patients are kept immobilized for safety and workload management.

Conclusion

Staff had positive attitudes toward caring for older adults; however, their understanding and application of geriatric principles were limited and remained unchanged. Interview participants stated their work environment limits their capacity to deliver the best practice care presented in the education sessions. These findings suggest that education alone is unlikely to influence prioritization of mobility for frail older adults in a strained acute care setting.

Introduction:

Advance care planning is a process that allows individuals to make decisions about their future healthcare, including end-of-life care, by discussing and documenting their preferences, values, and goals with healthcare providers and loved ones.These are especially critical for patients with serious, life-limiting conditions or for frail older adults who may face unexpected health crises.It is a commonly recognised barrier to care planning however that senior doctors often do not have the time to complete it for all patient’s who require them and that junior doctors lack confidence in having these discussions, this Quality Improvement Project aims at to increase the use of Advance care planning in the form of Emergency health care plan (EHCP) by empowering junior doctors to competently lead these discussions by introducing focused teaching on the topic to regular teaching.

Method:

Our objective was to organize teaching sessions for all junior doctors and LED doctors across University Hospitals of Leicester to educate them identifying suitable candidates and competently leading the discussion. So far we have delivered these sessions during Geriatric departmental teaching, IMT teaching and trust grade teaching and have gathered feedback to assess the teaching. We have also been collecting information on the total number of EHCPs completed by the trust over various periods, following the introduction of focused Advance Care Planning training into regular junior doctor teaching

Result:

After completing the original round of teaching, we found an overall improvement in the confidence that individuals had in both holding conversations about EHCPs and documenting the forms. 63.2% of participants now felt confident in conducting conversations, with 78.9% feeling confident to complete the EHCP form itself in the electronic system. As of now, we have not demonstrated an improvement in the number of EHCPs completed, with an initial result of 39 over the three months before teaching, compared to 36 after teaching. It was also noted that almost all EHCPs were completed in the context of advanced frailty and were not utilized for younger patients with terminal conditions.

Conclusion :

This initiative has been shown to increase junior doctors' confidence in leading ACP discussions, highlighting the need for such training to promote patient-centered care. Expanding this educational effort to include additional training for foundation-level doctors and GP trainees may further enhance advance care planning practices in hospitals. However, it is interesting to note that despite the perceived increase in confidence, the total number of completed plans does not appear to have improved. This may be partly due to our not yet targeting all relevant groups; future rounds of the project should explore the ongoing barriers to completion.

Introduction: Delirium is a common and serious complication in frail older patients undergoing emergency hip fracture surgery, often resulting in prolonged hospital stays, increased morbidity, and a greater risk of long-term cognitive decline. Recognizing and managing delirium effectively is critical in improving patient outcomes. However, initial assessments indicated variability in the confidence and capability of surgical postgraduate doctors to assess and manage delirium appropriately. A baseline survey revealed that 50% of staff were not familiar with hospital delirium guidelines, and 62% rated their confidence in managing delirium as 3 out of 5. Additionally, over one-third of staff inappropriately used the AMT10 as a delirium screening tool, and many lacked confidence in interpreting the 4AT score.

Method: To address these gaps, we implemented a multipronged educational program to improve staff knowledge and confidence in delirium assessment and management. This approach included formal teaching sessions, the display of delirium infographics in ward areas, and the dissemination of key information via email and WhatsApp. The program emphasized the appropriate use of the 4AT for screening and highlighted common delirium triggers and their management.

Results: Post-intervention analysis showed an improvement in both the confidence and accuracy of delirium assessment among staff. All staff were able to use the 4AT correctly, and everyone reported increased confidence in assessing delirium. Management practices revealed that pain, infection, constipation, and electrolyte abnormalities were generally well-addressed in patients. However, there remained a lower frequency of medication reviews, along with insufficient attention to nutrition and hypoxia as potential contributors to delirium.

Conclusion: Our educational intervention significantly enhanced staff confidence and competence in detecting and managing delirium in the trauma and orthopaedic ward setting. Following these improvements, the next phase of our project is to introduce a standardized delirium care bundle in the surgical setting. This care bundle aims to establish a structured approach to delirium management, thereby minimizing delirium-related complications and improving overall patient care.

Background:

There is limited understanding of the confidence of nurses and allied health care professional management of acute medical problems on rehabilitation wards. Health Education England (HEE) has developed a teaching resource named ‘Bitesized Teaching’, originally developed for mental health staff. We aimed to review ward staff access to teaching and implement a quality improvement project to improve access to teaching in a multidisciplinary team setting.

Methods:

An questionnaire was administered to staff to understand the frequency of teaching they receive. A ‘bitesize teaching’ scenario was selected. The session covered the signs, symptoms, and basic ward level management that can be expected from ward staff. An anonymous pre-session and post-session feedback questionnaire was distributed.

Results

18 members of ward staff completed the initial questionnaire. The majority of participants had infrequent teaching (once every 3 months). All expressed an interest in bitesize teaching. A hypolgycaemia bitesize teaching session was selected based on staff feedback. 5/12 members of staff completed the pre-session questionnaire and selected ‘not confident at all’ or ‘slightly confident’ response to the recognition and initial management of hypoglycaemia. Post-session only 8/11 participant reported ‘extremely confident’ or ‘quite confident’ in this domain. 

Conclusion

The ‘Bitesized Teaching’ approach was considered an acceptable form of teaching and well-received by the multidisciplinary team in a rehabilitation ward setting. The majority of ward staff expressed an interest for this form of teaching to be incorporated into a weekly schedule in the long term and can be beneficial for new and existing members of staff.

Introduction: Hospital at home (HAH) is growing apace in the United Kingdom, offering hospital-delivered treatments at home. In parallel, increasingly structured alternative training pathways are being created to enable doctors to train outside of formal specialty training programmes. With a need to train doctors to work in community settings, a HAH rotation within a locally developed internal medicine training (IMT) programme at one large NHS Foundation Trust was evaluated.

Method:

A questionnaire was designed to review the alignment of HAH rotation experience with the IMT curriculum and its acceptability as a clinical rotation within an IMT stage 1 equivalent programme. The questionnaire was distributed to all doctors who had previously undertaken a HAH rotation at junior clinical fellow level in the previous five years. Free-text responses were analysed with thematic analysis.

Results:

23/27 responded (85%). 74% had pursued IMT following their non-traditional training year. 78% agreed that HAH would be a suitable placement for a 4-month IMT rotation, with 74% interested in a HAH role following completion of training. HAH offers core content in internal and geriatric medicine. Curriculum coverage within a HAH rotation included improved confidence in clinical decision making, leadership, risk management, multidisciplinary team working and increased exposure to advanced care planning and palliative medicine. Being part of contextual, personalised medicine with shared decision making central was also cited as beneficial over traditional hospital rotations. Disadvantages were a lack of exposure to core IMT procedural skills, resuscitation and fewer opportunities to attend outpatient clinic.

Conclusion:

Whilst limited to one geographical service, results indicate that HAH is a prime learning environment for internal medicine training as part of a carefully balanced programme ensuring access to all curriculum competencies. Where sufficiently developed, HAH rotations can be included in IMT programmes delivering much needed generalist skills. 

Introduction

Despite the UK’s increasing life expectancy, and increase in the elderly population, there is an overwhelming lack of Geriatricians in the UK; as of 2022, there is only 1 consultant Geriatrician per 8,031 individuals over the age of 65 (BGS, 2023). To meet the complex care needs of this population, there must be a focus on increasing the interest that doctors have towards Geriatric Medicine, with the overall aim being to recruit more doctors into the speciality.

Method

The aim of this review was to investigate what factors medical students perceive as barriers to pursuing a career in Geriatric Medicine and then, from identifying these, generate a set of comprehensive suggestions as to how to tackle these barriers at a medical school level to increase the interest and ultimately uptake of Geriatric Medicine. The qualitative review contains literature published between 2003 and 2023 accessed using MedLine.

Results

Six themes were identified in answering our question: (a) high emotional burden, (b) caring for patients with complex needs, (c) negative preconceptions of non-clinical factors (prestige, salary, career progression), (d) negative influence of clinical educators, (e) lack of intellectual stimulation and (f) lack of exposure to the speciality and the elderly.

Conclusion

The barriers perceived by medical students when considering Geriatrics as a speciality are complex and multifaceted; these barriers must be tackled promptly in order to secure the next generation of Geriatricians. We suggest that this work can be used as a foundation for further qualitative studies with UK medical students to investigate barriers that are specific to UK students. From this, interventional courses designed to increase Geriatric Medicine uptake could be developed to strengthen the UK Geriatric Medicine workforce.