Improving service delivery

The acute care system is operating at maximal capacity, A&E is in an ‘awful state’, and there is continual rising of demand [1]. The ageing population is a triumph and challenge, with more living with frailty and complex needs [2]. Demand continues to escalate, and our services need to respond to this new reality [3]. 

Barnet Hospital is situated within the largest population of older people and with the greatest number of care homes in London. Our local ageing population provides opportunities to develop SDEC services for frail patients traditionally underserved and excluded [4]. For patients ≥65 and ≥80years with CFS≥5, conversion from attendance to admission is 72% and 76% respectively, with mean LOS on our geriatric wards 13.6days [5]. Despite embedded frailty initiatives, the traditional models of inpatient focussed care for those with frailty are unsustainable [3]. 

Barnet Hospital was an early adopter of Geriatrician and MDT presence within the ED, however a previous iteration of a front-door frailty service was unrecognisable and non-functional in 2024. This was driven by focus on expansion of Geriatric medicine inpatient areas, increasing capacity of rapid-access HotClinic and workforce shortages. 

With emerging evidence showing the oldest old waiting longest to be assessed in the ED, frail people waiting longest to be seen on the medical take, and increased mortality of those who remain in ED for longer, a new front-door Frailty Service was never more urgent [6,7,8]. 

Using quality and service improvement methodology, facilitated by a multidisciplinary working group, a new Frailty Service was planned, piloted and delivered despite staffing and infrastructure challenges. The service expanded, providing CGA to 20patients in June 2024 to over 80patients in January 2025, with 63% same-day discharge rate and excellent patient/carer feedback. With ongoing workforce challenges and changes to dedicated assessment areas, the team have learnt to adapt and work dynamically to provide an ever-improving service.

References: 

1. Darzi A, 2024. Independent Investigation of the NHS in England.​

2. Department of Health and Social Care, 2023. Chief Medical Officer’s Annual Report 2023.​

3. NHSE, 2024. FRAIL Strategy.​

4. GIRFT, 2024. Principles for Acute Patient Care. 

5. Royal Free London NHS Foundation Trust Frailty CPG (Clinical Practice Group), 2024. Barnet Frailty Dashboard.  

6. Maynou L, et al. 2023. Factors associated with older patients’ ED wait times. Emerg Med J.​

7. Knight T, et al. 2023. The impact of frailty and geriatric syndromes on metrics of acute care performance: results of a national day of care survey. E Clin Med.

8. Iozzo P, et al. 2024. Mortality risk linked to prolonged ED boarding of frail individuals. J Clin Med.​

Introduction

Physical and cognitive frailty combined with unfamiliar surroundings in hospitals puts elderly patients at high risk of falls. It has been demonstrated that patient-centred, non-clinical stimulating activities in hospital have been found to reduce agitation, improve affect and engagement, relieve pressure on nursing staff and reduce falls. In the Medicine of the Elderly (MOE) wards of an urban teaching hospital, after a successful pilot, a Meaningful Activity Team (MAT) was implemented. The effect of this change to patient and staff well-being was assessed, as was the frequency of falls on the wards.

Methods

The MAT was implemented by July 2023. In November 2023, questionnaires were distributed to staff across the MOE department to collect quantitative (Likert scales) and qualitative data on potential benefits and limitations. As part of our Quality Programme, prevalence of patients admitted to MOE wards with a diagnosis of dementia/delirium is regularly measured, as are patient falls, which are recorded via DATIX and collated on ward-based run charts. We interrogated these charts for any significant changes.

Results

The current prevalence of patients with delirium/dementia across the MOE 152 bed footprint is 69%. 49 staff questionnaires were completed, 47 of which had comments. 100% of respondents agreed or strongly agreed that the MAT benefited patient well-being. 87.8% agreed or strongly agreed that the MAT benefited staff well-being (figures 1, 2). Common themes regarding patient well-being were patients being happier, brighter and more sociable. Common themes regarding staff well-being included less stress and increased time for clinical tasks. The frequency of falls has reduced with some wards seeing maintained shifts in median number.

Conclusion

Implementation of the MAT across our MOE wards has improved patient and staff well-being. Reductions noted in frequency of falls have been maintained.

Introduction: Within our ward multidisciplinary team (MDT) meetings we noted that there was often a lack of attendance from key disciplines, inconsistent content, and an overly medical emphasis. We wished to create an MDT that was structured, with consistent input from nursing and therapy teams, covering components of comprehensive geriatric assessment (CGA).

Methods: On one pilot ward, we agreed a new structure to MDT meetings. Clinical leadership was required to facilitate staff sharing their observations, with clinicians speaking less. We used an A0 poster as a clear visual prompt for maintaining structure. A survey on teamworking and safety was performed on the pilot ward by the Improvement Academy. We had several iterations, but a standardised structure with key ingredients for MDTs was rolled out across five other Elderly Medicine wards. A further survey was performed examining opinions on quality of MDT working.

Results: After our interventions, CFS, 4AT and mobility went from being discussed 0% of the time in July 2021 to 100% of the time on the pilot ward between January and July 2024. Mobility went from being discussed from 0% in July 2021 to 71% in May 2024 across all wards. 90.5% of the pilot team thought that decision making utilised input from relevant team members. In a further survey in May 2024, 82.6% agreed that the relevant team members opinions were listened to.

Conclusion: A structured MDT process was successful in incorporating key elements of CGA whilst improving MDT teamworking. Starting with a single ward allowed others to gain confidence in the success of the process and enable natural spread. Key stakeholders including organisational leads were consulted and involved in improvement work, such that this is now a standard way of working. The lessons learned are being used to contribute to a digital dashboard tracking MDT progress.

Introduction-

Treatment Escalation Plans (TEPs) and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms are vital in hospital care, providing clarity on patient management while considering patient wishes. Though DNACPR decisions ultimately lie with doctors, discussions with patients or relatives foster understanding. Factors such as comorbidities and the Clinical Frailty Scale (CFS) influence these decisions. Proper form completion guides patient care and helps prevent adverse outcomes, but incomplete forms often lead to challenges for medical teams.

Objective- 

This quality improvement project aimed to educate doctors on completing these forms to improve patient care.

Method-

Data were collected on TEP and DNACPR form completion across hospital wards, focusing on CFS, comorbidities, consultant approval, and patient/family involvement. Teaching sessions and educational leaflets were provided to doctors to enhance understanding. Post-intervention data were collected and analysed.

Results-

Two audit cycles were completed: the first with 156 patients, the second with 129. Compliance to Consultant approved DNACPR form completion increased by 9% (from 79% to 88%). Patient and family involvement in DNACPR decisions improved by 2% (from 84% to 86%). Documentation of comorbidities increased by 6% (from 20% to 26%), and CFS documentation improved by 5% (from 13% to 18%), though overall levels remained low.

Conclusions-

The interventions improved doctors' understanding of the importance of completing TEP and DNACPR forms, rationalising patient's care.The study highlights the crucial role of these forms in managing hospitalised patients and providing timely, appropriate care.Continued education through teaching and informational leaflets is essential for better patient outcomes.

Introduction:

The Gloucestershire Frailty Virtual Ward (FVW) is a novel multidisciplinary collaborative project which seeks to improve care for frail older patients. We describe our experience, reflect on lessons learnt and plans for future service development.

Methods:

The Gloucestershire FVW was started in early 2023. It arose from an understanding that the needs of frail patients can often be better met in their own homes, by utilising a combination of digital technology combined with improved working across organisational boundaries at the primary/secondary care interface. We reviewed data from all patients admitted onto our FVW between October 2023 and March 2024.

Results:

66 patients were included. The majority of patients were ‘step-down’, having been in hospital prior to FVW admission. The minority were ‘step-up’, having been referred from community colleagues. Clinical frailty scores ranged from 2-8, with a mean of 6. During this period, our FVW managed a range of different clinical problems. The most common reason for FVW admission was infection, then heart failure, delirium and acute kidney injury. Most patients were admitted for the management of a single problem (58%), although a significant proportion had 2 or more problems (42%). Our FVW conducted a variety of interventions, including blood tests, face-to-face reviews, amending medications including antimicrobials, diuretics and analgesia. Our FVW was also involved in decisions around the withdrawal of active care and initiation of a palliative approach.

Conclusions:

Our FVW has helped facilitate early discharge and avoid hospital admission, with associated benefits to both patients and the acute trust. As a new service which aims to sit between primary and secondary care, we have encountered logistical and governance challenges associated with working across organisational boundaries. Additionally, we have found that the use of digital technology can cause anxiety for patients and place additional strain on carers.

Introduction

Board round is essential in geriatric care for clinical prioritisation, planning discharges and identifying any barriers to discharge. This process can be limited by poor handover, lack of roles and a defined structure. This project aimed to improve board round efficiency in an inpatient acute frailty setting.

Methods

The project involved a 2 stage PDSA cycle including data collection at baseline and after each successive intervention.

Stage 1: Role allocation and Board round proforma

Stage 2: Doctor education

Data related to several outcomes was collected retrospectively over 4-5 days per cycle. Inclusion criteria included all inpatients on the acute frailty unit at the time of each daily morning board round. Qualitative data was collected at baseline and after cycle 1.

Results

Improvement was shown in all outcomes after two cycles:

• Board round length (<30 minutes)
• Principal problem listed correctly (33% to 76%)
• Medically fit patients marked correctly (57% to 83%)
• Time since problem list last reviewed (11 days to 1.9 days)
• Proforma completed (89%)
• Proforma visible in the patient notes (68%)

Conclusion

This project demonstrated improvement in terms of accuracy and efficiency to the board round process. This has implications for geriatric patient care and flow.

The format has been rolled out to other medical wards across the trust helping to standardise the board round process.

A further intervention of a ‘Smartphrase’ and teaching sessions to facilitate updating the problem list has been implemented with further data collection planned.

Background

Evidence shows that CGA based in Frailty units is better for patient care (Fox 2012, Ellis 2011). University Hospital Wishaw (UHW) is the only acute site in NHS Lanarkshire that does not have a frailty assessment unit as part of the admission/receiving pathway. Patients are currently admitted to the Medical Assessment Unit (MAU) and seen by either Geriatrician or Medical consultant depending on the time of admission. UHW is working towards a frailty unit but has been limited by space and resource. Instead we have been on a journey of step-wise improvements to establish one.

Methods

Over the course of 5 days, we developed a Rapid Access Frailty Team (RAFT) in a cohort of 10 beds within the existing MAU. Patients were over 65 and had a CFS ≥5. Patients were reviewed by a Geriatrician in morning and afternoon, and had MDT input from Physiotherapy, Occupational Therapy and a Nurse specialist.

Results

Over the 5 days 28 patients were admitted to RAFT beds. 9/28 (32%) were discharged from RAFT. Length of stay was 32 hours. Patients either went home or moved to a downstream ward if needed. Medical and AHP staff feedback was positive, but nursing staff in MAU voiced it was onerous having all frail adults in one area.

Conclusions

Development of frailty area within a medical assessment unit is possible and appears to lead to improved outcomes and discharge rates compared to non-cohorted areas. We are now looking for an area where we can apply our RAFT principles and have more staff support.

Introduction 

Prompted by observation and directed by The Centre for Perioperative Care (CPOC) guidelines, two quality improvement cycles were carried out during 2021-2023 seeking to improve the identification and care of frail patients admitted emergently to the general surgery department at Peterborough City Hospital (PCH), a busy district general hospital with over 40 general surgical beds. 

Method 

Two Plan-Do-Study-Act cycles were undertaken. The medical records of patients 65+ years were interrogated for documentation of frailty assessment, evidence of escalation planning and geriatrician review. Results were presented at departmental clinical governance meetings where the barriers that are limiting progress in this area of clinical practice were debated. In view of finite resources and funding, realistic measures, such as highlighting frailty scores during handover, were introduced during both cycles. 

Results 

Both cycles demonstrated that current practice within the general surgery department at PCH does not meet CPOC standards and no significant improvement was made by simple interventions. Frailty scores are not routinely assessed or utilised by clinicians, only some patients are given opportunity to undertake shared decision-making including escalation planning and a small number of patients receive a geriatrician review. Departmental discussions revealed barriers including lack of knowledge of frailty, insufficient communication within the department, and insufficient resources for specialist geriatric input. 

Conclusion 

This project has demonstrated the challenges of changing clinical practice on the front line. Although our results demonstrated no significant improvement in care of frail surgical patients, change has occurred in terms of engagement of general surgeons. Gold standard practice seems elusive, but small, realistic steps are being taken. Whilst there is no immediate prospect of the resources to deliver specialist geriatric input for all frail surgical patients, there is hope that progress can be made towards this so we will continue to build a case for future investment. 

Introduction

Introduction of the medical examiner (ME) service has changed the process in which the Medical Certificate of Cause of Death (MCCD) is completed across South Wales. In a tertiary hospital we endeavoured to improve team ownership of medical cause of death decisions, senior involvement, and communication of this to the medical examiner service, through development of a new process and communication form.

Methods

Two PDSA cycles have been completed. With stakeholder involvement we produced a process map and developed a Proposed Cause of Death form. In 2022 medical teams on 2 wards (A&B) trialled a new process - to discuss as near as possible after death the likely cause of death and submit a Proposed Cause of Death form. We collected data on number of deaths, number of forms completed and time between death and MCCD completion. In 2023 a task and finish group developed an electronic form and piloted on a further three selected medical wards (C,D&E).

Results

Cycle 1: Mar-Aug 2022. Proportion of deaths with form completed: Ward A 0%(0/25), Ward B 71%(27/38). Time from death to MCCD completion was not increased by form implementation (3.1 days after vs 4.7 days before). Cycle 2: Aug 2023–Jan 2024. Proportion of deaths with form completed: Ward C 60.9%(14/23), Ward D 0%(0/22), Ward E 5.3%(1/19). Time from death to MCCD completion increased by only 0.6days compared to 3 control wards (5.7days vs 5.1days).

Conclusions

The process and form were successfully adopted on 2/5 wards. Facilitators of adoption were ward level consultant engagement and prompting of the medical team by the bereavement team. Barriers to adoption were a perception of extra work and being unable to perceive usefulness of the process. Ongoing work aims to improve team motivation through education and recruitment of ward 'champions', and rollout to additional wards.

There is unequivocal evidence to support Perioperative care for the Older Person Undergoing Surgery (POPS) services. However, POPS services are not available in all Trusts offering surgery, including Royal Surrey Foundation Trust (RSFT). The necessity for POPS services will continue to grow with increasing numbers of older people undergoing elective and emergency surgery due to: changing demographics, surgical and anaesthetic advancements, shifts in culture and patients’ expectation of healthcare (1). A RSFT POPS steering group was convened to explore the current orthopaedic elective pathway, the what-why-how of implementing a POPS service and ultimately write a business case to submit to the board to request funding for a formal POPS service. Unfortunately, ahead of submitting we were informed a business case would unlikely secure funding due to the current financial climate. To continue to evidence the need for this service, over the course of a year, Geriatricians used their Supporting Professional Activities (SPA) time to provide informal POPS Comprehensive Geriatric Assessment (CGA) reviews to patients aged ≥65 with a CFS ≥5 on the elective waiting list for knee/hip operations. The average age of patients seen was 82 years (range 67-92). The average Clinical Frailty Score calculated was 7 (range 4-7) with the average number of frailty markers identified being 4 (range 1-7). Following CGA, 75% of patients decided not to proceed with operative management. 88% either initiated or completed a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT). We now have both local and national data to support the need for a POPS service at RSFT. When financial support is not available to invest in and develop new services, alternate methods such as staff re-distribution can be considered with the aim of both providing a service as well as collating invaluable evidence to support a business case and secure funding.