Improving service delivery

Pulmonary embolism (PE) is the third most common among acute cardiovascular diseases, after myocardial infarction and stroke, with a significant mortality rate. At Portsmouth University Hospital's acute medical and respiratory departments, inadequate understanding of pulmonary embolism diagnosis and management, which led to unnecessary investigations and medications putting the patients at risk of the side effects and complications of that, was the main impetus for initiating this audit. The hospital did not adhere to the NICE recommendation of regular interim anticoagulation for patients awaiting imaging for probable PE. A significant number of patients unnecessarily admitted to the hospital due to PE could have benefited from outpatient treatment. We collected data for eight weeks both before and after the implementation of the new hospital PE pathway, following a baseline audit and PDSA-based problem-solving, which underscores the significance of accurately utilising the Wells Score and PE rule out criteria (PERC). We obtained PE diagnosis criteria from NICE standards for comparison. The new hospital PE pathway was a result of the initial audit. The results from the re-audit showed an improvement in documentation and calculation of the Wells score from 16.1% to 66.1%, the PERC score from 9.1% to 58.3%, and the PE severity index (sPESI) score increased from 9.1% to 58.3%, as well as an increase in the number of junior doctors who initiated the PE pathway from 19.6% to 41.9%. Additionally, the proportion of inappropriately requested investigations, such as D-dimer and CTPA, was reduced. Also, the number of CTPAs requested in line with the guidelines increased from 11.11% to 52.27%, and the diagnostic yield of PE on CTPAs increased from 36.08% to 64.85%. A simple diagnostic pathway resulted in a decrease in unnecessary investigations and an increase in the diagnostic yield of PE.

Abstract Content - 'The number of patients being diagnosed with Heart Failure (HF) on a global scale continues to rise, placing a huge strain on the National Health Service (NHS). Caring for patients with HF comes with huge cost implications and exacerbates an already growing economic burden for healthcare systems. HF care needs to be standardised and integrated if we are to provide optimal care. Evidence shows that there is potential to improve the detection, diagnosis and management of HF care through innovative care pathways when delivered consistently through strong leadership and collaborative working. A care pathway for clinical nurse assessors was developed and implemented to guide and steer HF care within an 'Out of Hospital' clinical team; create a streamlined process to move patients with HF from one service to another; and encourage collaborative working amongst HF services. In addition, weekly HF MDT meetings were introduced in an attempt to reduce hospital admissions.

The Model for Improvement Framework was used to provide structure and support the change management, along with the RE-AIM Framework which facilitated the implementation of this pathway and supported the translation of this project into practice. 

Following the introduction of the care pathway, comparative data was analysed and the results showed that first line steps in the diagnostic pathway were being carried out quicker in patients presenting with HF symptoms, the time taken to refer on to cardiology services was significantly quicker, and all patients presenting with HF symptoms had a BNP blood test carried out on initial assessment. In addition, the length of time patients remained on the 'Out of Hospital' caseload and the number of hospital admissions were significantly reduced. The results also showed that the majority of patients on the pathway were treated in the comfort of their own homes and the number of patients referred to cardiac rehabilitation had vastly improved.  

To conclude - integrated care pathways together with high level government strategies are vital in the re-organisation of HF care and the standardisation of interconnected guideline-based care and management. Implementing a HF care pathway not only streamlined care for patients diagnosed with HF within the community setting but it had a positive impact on patient outcomes, quality of life and hospital admission rates. The pathway provided clinical nurse assessors within the 'Out of Hospital' team with a structured and standardised approach to HF care and having regular HF MDT meetings significantly improved the outcomes of people living with HF, as complex cases could be managed quicker and more effectively and hospital admissions could be avoided. Communication channels and relationship building between specialist services were also enhanced as a result of the pathway. 

Introduction 

Enhanced care units (ECU) are a novel concept, targeting the gap between ward-level and critical care. They care for patients requiring intensive medical or nursing care, who may not require, desire, or be suitable for, escalation above ward care (Society of Acute Medicine and Intensive Care Society, 2022). The ECU at Barnet Hospital opened in March 2022, and, because of the local population demographic, admits a high number of older patients living with frailty. We aimed to assess the performance of the ECU for this subset of patients. 

Methods

A retrospective audit of electronic records of 75 randomly selected patients admitted to ECU between March and August 2023. Data were gathered on Clinical Frailty Score (CFS) at baseline, comorbidity, escalation status, APACHE II illness severity score, and outcome measures. 

Results

The majority of patients in the sample, 52 of 75 (69.3%), were over 65 years of age with an average of 69.1 years. Baseline frailty score was high, with a modal CFS of 6. Of these patients, 32 (61.5%) had a DNACPR, and 16 (30.8%) had treatment ceiling at ECU level. Illness severity was similar across CFS groups, with a mean APACHE II score of 15.2 (representing a 25% mortality risk). Overall mortality in the over 65s was 23.1% (12/52), without significant change when stratified by CFS. Mortality in the under 65s was 8.7% (2/23). 

Conclusions 

Acutely unwell patients with frailty may benefit from ECU level care. In our centre, we found no significant increase in mortality linked to a higher frailty score. We suggest that this may represent good case selection by clinicians experienced in working with frailty: admitting patients with more reversibility and targeting therapies towards reversible causes. Limitations remain, especially in assessing illness severity, as the assessment tools are not targeted to this cohort.  

Introduction. The multidisciplinary assessment clinic (MDAC) is an outpatient service for older people at a district general hospital. Patients are triaged to the MDAC clinic if they have geriatric syndrome (for example falls) plus comorbidity and/or mobility, social or cognitive concerns. The service had a high ‘did not attend’ (DNA) rate compared with other geriatric outpatient clinics. This project aimed to reduce MDAC DNA rates and improve cost effectiveness through implementation of a new pre-appointment telephone service.

Method. We analysed six months of attendance data prior to establishing the pre-appointment telephone service. The existing system consisted of a standardised trust appointment letter and a text message reminder. For the new system a healthcare assistant (HCA) telephoned patients the day before their appointment to confirm attendance and discuss any concerns. We analysed six months of attendance data following the implementation of the new system and compared DNA rates.

Results. Prior to implementation of the new pre-appointment telephone service, 29 of 268 patients DNA (11%). From the second data set, following implementation of the new telephone system, 11 of 253 patients DNA (4%). Successful contact was made with 72% of those phoned, allowing confirmation or cancelled appointments to be rebooked. Chi square analysis found a significant difference between the two systems, with a p value of <.01 indicating an improvement in attendance rates with the new system.

Conclusion. Telephoning frail older patients prior to outpatient clinic appointment significantly reduces DNA – a similar system could be implemented other geriatric medicine settings.

Introduction

Older people living with frailty are at high risk of adverse clinical outcomes following emergency laparotomy, including early death, hospital readmission and functional decline. Despite this, there is a paucity of literature exploring patient experience of surgery in this group, particularly following hospital discharge. As a result, there is limited information to guide the development of service delivery models that support optimal post-operative recovery and improve overall experience

Methods Twenty older people, aged ≥65 years, with a Clinical Frailty Scale score of ≥ 4 and who had undergone emergency laparotomy were recruited from eight participating hospital sites. Participants were interviewed at 3 weeks following their surgery, or the earliest convenient date. Semi-structured interviews were undertaken either face to face or via telephone and explored the peri-operative and early recovery experience. Data were analysed using reflexive thematic analysis

Results Participants described physical, psychological, and social implications following emergency laparotomy which extended further than hospital discharge. Recovery was perceived to be an ongoing and slow process of returning to ‘normal self’ however participants displayed resilience towards achieving this by ‘knuckling down’ and ‘pushing forward’. The experience of hospital care was generally positive, but lack of access to discharge advice and community follow up left some participants feeling ‘abandoned’ and uncertain once they returned home. Many were reliant on family support during this period

Conclusions Older people living with frailty experience multifaceted consequences of emergency laparotomy that result in a prolonged recovery period. Multi-disciplinary post-operative care pathways are essential in addressing the holistic care needs of this group following surgery. The provision of robust discharge information and enhanced access to support in the community could improve patient experience and facilitate ongoing recovery at home.

Introduction: Meaningful involvement of experts by experience in the design of health and care research is now well-established as good practice (Staniszewska, 2018). For example, it is essential that the voices of residents and staff are properly heard in care homes research, since they provide important perspectives not necessarily shared by the wider multidisciplinary team (Shepherd et al. 2017). Nevertheless, there are concerns that involvement can be tokenistic, or vulnerable to power imbalances (Baines & de Bere, 2017; Jennings et al., 2018).

Methods: A care home in north east England is working with researchers to pioneer a new approach to involvement, with residents and staff at the centre. The care home has helped to shape a number of research projects, for example a feasibility study of mealtime care training. In this study, an advisory group was set up initially within the care home itself, comprising residents, staff and family carers. Subsequently the group was joined by people from other care homes in the area, with support from the local authority. In parallel to this, health and social care professionals have contributed to the advisory group through one-to-one meetings with the researcher.

Results: Advisory group meetings in the care home have provided an inclusive and equitable platform for residents and staff to share their views on the research topic and design. Other stakeholders have been able to input into the project, but separately and in a way that has left room for key voices to be properly heard. Contributors have felt valued and are keen to continue in the process.

Conclusions: This study offers an alternative and authentic model for the involvement of experts by experience in social care research, inverting the more typical approach so that residents and staff are at the centre not the periphery.

Aims

This closed loop audit aims to primarily assess and improve the number of geriatric patients who fell on elderly wards in a District General Hospital using cost effective methods. The secondary aim is to improve documentation of falls and assess for contributing factors. Hypothesis The primary hypothesis is that number of falls can be reduced through better nursing training and co-locating high risk patients. The secondary hypothesis is that improvements in documentation can be made with nursing training specified to falls and to corroborate risk factors with existing literature.

Methods

The first cycle was conducted between February 2021 to May 2021. Patients who were deemed high risk of falls, defined as over 80 years with at least 1 previous fall, were co-located. Nursing staff were provided with falls related training and how to report falls. The audit was repeated between the months of February 2022 and May 2022 to prevent seasonal bias. Results collected using the computerised internal patient records and paper documents. The number of falls, in addition to demographics, comorbidities, medications and complications were collected and compared.

Results

It was shown that cost- effective measures implemented in this audit significantly reduced the number of falls- down from 50 to 29 total falls across the same time period. We showed polypharmacy is a contributing factor to increased falls, with anti- hypertensive medications recurring as a repeated offender. 90% of those who fell were recurrent fallers, highlighting the importance of early identification of those at high risk.

Conclusion and further studies

This audit has highlighted the importance of simple, clinically effective and cost- effective measures in falls prevention. Further improvements, such as falls alarm for patients and refurbishing of ward layouts have been suggested by nursing feedback. Once implemented, the wards can be re- audited for further falls prevention.

Introduction  

The weekend on-call team attends ward emergencies and front door new assessments. The extra routine ward work results in delays in the new assessments and adds further exhaustion for the on-call team, impacting junior doctor’s well-being and patient safety.  

Objective  

Aim to improve patient safety by facilitating the continuity of patient care over the weekend 

Method 

Group discussions among junior doctors, nurses, pharmacists, and ward managers were done to understand the challenges that impact communication. The average time spent on a ward by on-call team was 60 minutes. Plan-do-study-act (PDSA) cycles were introduced. The key measurement used was the time taken to complete the ward task. 

Results 

Team agreed to focus on improving communication over weekends based on the number of times nurses contacted junior doctors 

Friday morning ward round was made mandatory for every patient and a check-list sticker was introduced to test the change for 15 patients. Results were assessed and showed 3 patients did not require review and saved 6 minutes of on-call team over the weekend.  

The second PDSA included 30 patients which showed 11 minutes of time saved. But change was not sustained. Awareness sessions were introduced, and the plan was to add an A4 sheet titled Mandatory Friday Round (MFR). Next PDSA cycles showed saving on-call team but not all the on-call team and nurses reviewed MFR.  

Team reviewed the results of the 5th PDSA cycle and agreed to use the green colour MFR A4 sheet and included prompts for the team to complete all the usual tasks. This saved about 28 minutes of on-call team.  

Discussion  

28 minutes saved from one ward was used for the new assessment. Team feels extending good practice to all 5 elderly care wards will save approximately 2 hours 

Conclusion  

Effective communication using MFR has enabled on-call team to assess extra new patients and have adequate rest.  

University Hospital Plymouth (UHP) provides secondary care to 475,000 people with a wider population of almost 2,000,000 people who can access its specialist services.

COVID pandemic had a significant impact of the outpatient list within the UHP NHS Trust and demonstrated that previously well-established model of Falls clinic was no longer fit for purpose. This resulted in a significant delay in waiting times for patients awaiting a specialist review.

A new model was designed to address issues and reduce waiting times for patients with Falls in the catchment area. The Pilot Multidisciplinary Team (MDT) Falls Clinic was introduced in July 2022 where patients are seen by a Falls Specialist Nurse, Advanced Pharmacist and Advanced Physiotherapist on the same day. All patients then are discussed at weekly virtual MDT meeting with Consultant Geriatrician where a decision is made whether patient could be discharged back to the Primary Care.

117 out of 149 patients have been booked into clinic. Only 57 patients (47%) were referred forward to the 1st Medical clinic. Out of 57 patients 31 have been seen and 10 were discharged back to GP following clinic attendance.

60 patients (51%) were discharged following review at the Pilot MDT Falls Clinic. 7 patients were re-admitted within the next 6 months after been discharged from the Pilot MDT Falls clinic. However, none of the admissions were related to Falls.

The waiting times were reduced by 4 months.

Funding was secured to run the clinic for the 12 months and the next step is to expand the team by employing another Advanced Pharmacist and Physiotherapist. The Pilot MDT Falls clinic demonstrated that a new approach is beneficial to patients. It also supports development of the skills for all team members though sharing expertise, knowledge and skills, and building team rapport.

The 2020-21 Chief Medical Officer report described Treatment Escalation Plans (TEPs) as ‘Realistic Medicine in action.’ Our aim is to increase TEP completion on the Medicine of the Elderly (MOE) wards at the Royal Infirmary of Edinburgh to >90% by July 2023.

Since August 2022, we collected weekly data from a single MOE ward. In October, we upscaled to include four MOE and one stroke ward. The notes of five randomly selected patients were reviewed weekly to see whether they have a TEP, and if so, which parts were completed. To further understand behaviours around TEP completion, we collected qualitative data asking doctors what the triggers and barriers were to TEP completion. 40% found the conversations challenging whereas 30% cited time and environment as barriers. We used this data to generate change ideas. For PDSA cycle 1, we developed a teaching session around TEP conversations. This is delivered regularly to all junior doctors and ANPs in the department. For PDSA 2, we allocated a weekly ward ‘TEP champion’ to highlight patients without a TEP and encourage completion.

Median for TEP completion was 75% on the initial ward, 42% over the four MOE wards and 20% for the stroke ward. All patients with a TEP had their resuscitation status documented. One third of patients did not have a TEP at all. Of the two thirds of patients with a TEP, a quarter were incomplete. Sections on goals of care, communication and interventions were completed in around half.

This project is ongoing with future PDSAs planned to address the barriers of time and environment. PDSA 3 will test the introduction of a mobile TEP phone to enable discussions in a quieter environment. The variation in practice in MOE versus stroke is important and requires further understanding of the barriers specific to stroke.