Improving service delivery

Introduction: Emergency departments are increasingly seeing more older adults living with frailty. Between 5% and 10% of all those attending EDs and 30% of acute medical units are older adults living with frailty. The consequences of this on the system manifests as increased patient length of stay, poorer patient experience and clinical outcomes, such as mortality and morbidity, are measurably worse.

Aim: The Acute Frailty team aimed to move and expand its resource to provide a service to frail, older adults in both the Acute Medical Unit and the Emergency Department. This aligns with a key National objective that recommends all type 1 EDs have 70 hours access to a Acute Frailty Service. The team are a liaison service and therefore work alongside the ED and medical teams.

Method: Quality improvement methodology was applied utilising multiple PDSA cycles. An incremental increase in provision of an Acute Frailty service within the ED. A stakeholder group was set up, KPIs were set. The team worked alongside the ED team to improve early CFS scoring for over 65s and embedded the Nationally agreed same day frailty criteria of CFS/4AT, EWS and the presence of a frailty syndrome to identify appropriate patients for the service within the ED. The CGA was initiated in parallel with the ED assessment.

Results: Time between admission and CGA decreased by an average of 30 hours, Time between CGA and dc from hospital decreased by an average of 1.6 days. The Acute Frailty team activity increased in the ED and decreased in the AMU and there was no increase in re-admission rate.

Conclusion: A CGA initiated in the Emergency Department had a positive impact on length of stay and the earlier dc did not increase readmission rates.

Background

The overlap between physical and mental health is a common challenge for older adults, and many live with co-occurring physical and mental health disorders. Different service models have been adopted; however, the majority provide specialist mental health input to older adults with physical health needs in acute hospital trusts. Few service models are available providing comprehensive physical health input to older adults in secondary mental healthcare settings. Furthermore, little information is available regarding specific physical healthcare needs facing older people receiving specialist mental healthcare. The aim of this qualitative study was to determine the facilitators and barriers to delivering physical healthcare for older adult patients, their carers, and staff within specialist mental health settings (inpatients and community).

Methods

54 semi-structured interviews (REC:22/IEC08/0022) were conducted with different stakeholders (staff (n=28), patients (n=7), carers (n=19)) across two mental health trusts (Leicester, Nottingham). Interviews explored the facilitators and barriers to delivering physical healthcare to older people (aged >65 years) receiving secondary mental healthcare (dementia and functional disorders) with combined physical health needs. Interviews were audio recorded and transcribed verbatim. Data were analysed thematically, drawing on an underpinning framework of integrated care for individuals with multimorbidity (SELFIE).

Results

Three main themes were identified: 1) service delivery; focussing on care coordination and communication between services, 2) workforce; focussing on training and skills alongside support and availability of physical health expertise, 3) the individual with multimorbidity; focussing on mental-physical health interplay and patient experience.

Conclusions

The findings from this study can be used to inform service development to improve the provision of physical healthcare for older people receiving secondary mental healthcare in the UK, focussing on improving care coordination and communication between physical and mental health services, and upskilling and training mental health teams in physical health provision with appropriate support from physical health experts.

Introduction: Our aim is to improve clinical efficiency by reducing avoidable discharge delays, increased number of discharges and availability of specialist Frailty beds. We intend to undertake 8 PDSA cycles with a new idea.

Background: 23 bedded Acute Frailty Short Stay Unit (AFU). Patient group defined as those admitted to the unit from April ’24 to current. Our initial spot-audit analysed 18 patients; the mean total avoidable delay was 31.52 hours (range 4.73- 123.3 hours). Initial analysis demonstrated that delays became longer throughout the course of the day. Methods: We evaluated staff opinions on the discharge process with a survey. Outcome measure identified as number of weekly discharges and appropriate patient flow to the AFU. Balancing measure identified as number of readmissions within 48 hours. PDSA cycle 1 allocated a doctor to write discharge letters during MDT. PDSA cycle 2 allocated a suitcase symbol to a potential discharge in the next 24 hours. We then adapted the suitcase with colours to differentiate between ready and awaiting investigations/ aim home in 24 hours. The next involved allocating a discharge doctor to review patients with an amber suitcase from the previous day first.

Results: Initial staff feedback has been positive. Data demonstrated an increase from the baseline (from below 20 to an average of 25 discharges a week). This then dipped throughout May, during which time there was an unusual level of escalation, staff absences and annual leave. The data has begun to recover to a high of 27 discharges in the week of the start of June.

Conclusions Utilising the MDT has been vital in the sustainability of the project. On-going staff surveys and regular meetings will help to ensure sustainability. Ongoing focus and further cycles are on encouraging junior members of the team to be involved with the intervention.

In hospital incontinence increases length of stay (1), in orthopaedic patients is associated with increased likelihood of discharge to an institutionalised setting (2) and can have a major negative impact, with many rating bowel and bladder incontinence as a health state the same or worse than death (3). Yet of the Geriatric Giants, it is given relatively little attention.

At a busy teaching hospital, we sought to raise awareness and improve management of incontinence across our 167 beds, by using a standardised, multi-disciplinary approach involving identification of patients and use of the components of BASICS (Bladder diary, A physical assessment, Symptom profile, Infection and Constipation check and a bladder Scan, figure 1).

Baseline data of a sample of 14 patients with new urinary incontinence with their aspects of continence assessment were added to a cumulative audit. Alongside checklists, a poster(figure 2) was designed and placed on each ward, a local teaching session about incontinence was delivered, and data shared at our local governance meetings. Following this, a further cycle of audit was performed. Reversible causes were identified and addressed appropriately. Between cycle 1 and 2 (February and June 2024), significant improvements were seen in most aspects of BASICS assessment with notable increases in use of the bladder diary (7 to 50%) and medical examination (7 to 57%). See figure 3 for breakdown.

As a consequence, there were multiple interventions aiming to improve patient symptoms. Paying consistent and sustained attention to this neglected area of practice has demonstrated a change of culture is possible. We are now incorporating continence assessment into our medical trainee audit programme to support a sustained multi- disciplinary approach and maintain improvements.

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:

A Clinical Audit was recommended by the ME following identification of potential safety signal because of possible non-compliance with guidelines on Anticoagulation in AF. The audit data collection tool was developed in discussion with the Chief Pharmacist and took account of up-to-date prescribing guidance from the Integrated Commissioning Board (ICB). Aim of the audit was to identify if, as per NICE guidelines patients had: o Risk for stroke (CHA2DS2-VASc) and bleeding (ORBIT) is assessed upon new diagnosis of AF? o Made aware of their risk assessments and involved in discussion regarding risk -vs-benefit of anticoagulation o Anticoagulation prescribed as per national recommendations.

Objectives:

To ensure that patients with new diagnosis of atrial fibrillation are assessed for stroke and bleeding and involved in discussion regarding anticoagulation which is prescribed as per national recommendations. Methodology: This local audit was carried out by analysis of both electronic and paper-based patient records using an Excel spreadsheet for analysis. Data was then analyzed with the help of the Senior Clinical Effectiveness Advisor.

Results and highlighted risks:

It was observed that in most cases (82%), patients were not made aware about the condition and associated risk of stroke due to underlying AF. They were also not involved in discussion regarding commencing lifelong anticoagulation, and not explained the benefits and risks of anticoagulation. Omittance/Ignorance of anticoagulation upon new diagnosis of AF hence increasing the risk of stroke with lethal consequences of preventable death in 21% of patients.

Recommendations & Conclusion:

Formulation of “AF Anticoagulation Checklist” (based on NICE guidelines) ensuring every patient with a new diagnosis of AF has a repeat ECG for confirmation of diagnosis, CHA2DS2-VASc and ORBIT scores for risk assessment, their renal functions and coagulation profile checked, followed by discussion with patient regarding results of risk assessment and risk vs benefit of anticoagulation.

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.