MDT

Introduction

Frailty is a condition with increasing prevalence in the UK and significantly impacts the lives of those affected and their families. Frailty is a condition best managed by teams of skilled multi-disciplinary health and social care professionals (HSCPs). It is therefore essential that all HSCPs working with older people living with frailty are equipped with the appropriate knowledge and attitudes to look after affected persons.

Methods

The British Geriatric Society (BGS) and NHS England (NHSE) collaborated to produce an online e-learning module to support HSCPs to provide frailty care in complex situations and lead frailty services. This module was developed in line with the NHS Skills for Health Frailty framework of core capabilities at the tier 3 level. The e-learning module was launched in October 2023 and contained 4 modules: Understanding and Communicating Frailty, Identifying Frailty, Supporting People Living with Frailty and Building Systems Fit for Frailty. This module was made available for free to BGS members.

Results

Between October 2023 and January 2023, over 4000 HSCPs registered for the online module. A wide ranges of HSCPs signed up for the module with nursing staff, advanced clinical practitioners, consultant geriatricians and physiotherapists the most commonly represented groups. 92% of those who completed the module agreed or strongly agreed that the course helped develop knowledge, understanding and confidence in frailty. 91% of those who completed the module said completion of the course would help them to further improve patient care and clinical practice. Areas identified to enhance the module further included addition of further case studies and making the resource more adaptable to all UK regions.

Conclusions

e-Learning can be an effective facilitator of frailty education for a wide range of HSCPs.

Background: Clinical pharmacists are increasingly working as part of primary care teams in UK. Many people living with dementia live at home with the support of primary care. Given the complexity of their health problems and their use of several medications, clinical pharmacists may potentially play a crucial role in their support Aims: To explore clinical pharmacists’ experiences of working in primary care with people living with dementia and identify any specific training needs to provide effective support for this patient group.

Methods: An online survey sent via email in 2023 through professional organisations, social media, and utilising research team contacts. The survey covered topics including clinical pharmacists’ background, experience of working with people with dementia, and training needs.

Results: 57 clinical pharmacists responded to the survey; the meantime working as a clinical pharmacist was 9.6 years (standard deviation 8.6) and within a primary care setting was 6.1 years (standard deviation 6.1). Just over three-quarters of respondents (n=31, 77%) work with people living with dementia. While almost two thirds (n=35, 61%) had undertaken training for dementia care, such training often lasted a few hours (less than a day) (n=17, 49%). Most respondents (n=39, 89%) wanted further information or training; including non-pharmacological interventions to improve quality of life in dementia and how to support carers and relatives. Practice challenges reported included a lack of face-to-face consultations and getting assurance that the patient could safely take medications.

Conclusions: These findings indicate an interest in dementia care, a willingness to undertake further training but practice uncertainties that suggest a system approach might be beneficial.

INTRODUCTION: As part of a larger quality improvement project focused on improving the management of older people living with frailty attending the Manchester Royal Infirmary, a Frailty Same Day Emergency Care Unit (Frailty SDEC) was established. This would require the merging of three teams: the Front Door Frailty team, the Acute Therapy team and an established Nursing team on the allocated ward area. It became apparent that an intervention was required to improve team-working and efficiency among these clinicians who had never all worked together in the same space before. METHODS: Board Rounds are well established elsewhere in the hospital and are recommended by the Royal College of Physicians’ Principles for Best Practice. We therefore tested, through four Plan-Do-Study-Act (PDSA) cycles, the approach to Multidisciplinary team (MDT) board rounds that would facilitate teamwork and efficiency in the team. RESULTS: Our main outcome measure was staff satisfaction. There is evidence that increased staff satisfaction improves patient outcomes; this is therefore an important metric. Furthermore, there would be other confounders on efficiency such that time to discharge would not have been an accurate measure of the impact of good board rounds. We therefore surveyed the MDT after 6 months of working through the PDSA cycles to compare the current practice with what had been the status quo at the start of the year. The overwhelming response (both quantitative and qualitative) was increased satisfaction with how the team was working together to improve patient care. CONCLUSION: When setting up a new service, early attention must be given to how to ensure that newly created teams have their own personalised approach to collaborative MDT working, by establishing a Board Round culture that works for that team.

Introduction

University Hospitals Dorset (UHD) wants to provide hospital level care to patients with frailty, in their own home. Our frailty virtual ward (VW) team consists of a consultant geriatrician, lead nurse, pharmacist, advanced nurse practitioner, nurses and therapists. We have a capacity of 20 patients across Bournemouth, Christchurch and Poole localities. Our patients receive care at home for acute medical conditions supported by remote monitoring, blood testing, face to face assessments and daily Geriatrician input. We are collaboratively working with our community partners seeking to provide complete CGA in the patient’s home.

Methods

Establishing the service was non-linear and required multiple improvement cycles. Our VW fits alongside our frailty SDEC, day hospital and interim care team. We developed a SOP, a patient flow pathway and processes for medication prescribing and delivery supported by the Royal Voluntary Service. We screened our frailty wards for suitable patients and in May 2023 we tested by taking our first patient home. Subsequently our processes have developed around the patient’s needs. Through multiple PDSA cycles we tested various screening techniques, 7 day Geriatrician input, nurse recruitment, remote monitoring and used patient feedback to guide further service development and improvement.

Results

We are an established frailty virtual ward with 20 beds.

Conclusion

The UHD Frailty VW has developed out of a need for an early supported discharge and admission avoidance for our older patients. Through multiple PDSA cycles, we have established a virtual model that we feel is providing safe, hospital level care for patients with acute medical presentations. We hope to expand through recruitment and funding with an aim to deliver excellent quality care to patients with frailty in their in their own home. Our ambition includes closely working with South West Ambulance Service for further admission avoidance and developing a home IV pathway.

Introduction

Incidents and complains are an important form of learning for healthcare institutions. The learning is often shared via huddles, handovers, emails and learning alert bulletins. In the older persons medicine (OPM) department at James Cook University Hospital, we identified that there may be a role for whole team in-situ sim to not only facilitate learning around important and highly relevant topics but also improve the education provision for nurses and healthcare assistants who have less access to education compared to their doctor colleagues and improve whole team communication.

Methods

Initially a working group including a consultant, advanced clinical practitioner, SIM training facilitator, liaison psychiatry nurse, teaching fellow and ward manager was set up to organise a pilot session. Following the success of this session the training was initially organised to be monthly, arranged by the advanced clinical practitioners, facilitated by the sim technicians. The ward managers fully supported the training and facilitated the attendance of the ward staff. The clinical director identified topics for learning from incidents and complaints and there was support from the OPM registrars and teaching fellow. It quickly became so popular amongst staff that the session frequency was increased first to fortnightly and is now run weekly.

Results

The feedback was excellent. From the attendees, to the sim trainers who said that the OPM department had been the most enthusiastic about ward-based training. The anonymised and entirely positive feedback from the sessions was that they were interesting, informative, and relevant to clinical practice.

Conclusion

Using in-situ simulation training on the older persons medicine wards to share learning from incidents and complaints is not only practical, but incredibly well received by staff of all disciplines.

1. Introduction

Care home residents have a greater incidence of frailty and co-morbidities. Polypharmacy and inequitable access to integrated healthcare are confounders to positive outcomes in this cohort. Providing proactive care through the Enhanced Health in Care Homes (EHCH) Framework seeks to address these inequalities using multidisciplinary team (MDT) working.

2. Method

A pilot MDT intervention was delivered across eleven older peoples care settings with the most ambulance conveyances in a London borough known for its aging population. MDT members were from general practice (including pharmacist), geriatrics, ambulance service, district nursing, palliative care, psychiatry, social care, integrated care board and senior care home staff. The intervention was refined iteratively over five months via a Plan-Do-Study-Act cycle. The MDT undertook comprehensive geriatric assessments, advance care planning and structured medication reviews. Outcomes were documented in personalised care and support plans (PCSP).

3. Results

Sixty-nine of the most complex patients were selected to receive the intervention. 100% of these patients had a PCSP created post-intervention. A resultant system culture change led to a three-fold increase in the number PCSPs across all care settings. There was a reduction in 999 calls for 57% of MDT patients (across 8 settings) and there was 24% fewer 999 calls and hospital conveyances across the wider patient group in all MDT care settings. MDT professionals and care home staff reported high satisfaction and valued shared learning and clinical decision-making.

4. Conclusion(s)

This intervention addressed health inequalities of care home residents with a clear thread of advocacy for patients. Proactive personalised care planning offered opportunities for earlier diagnoses, treatment, and swifter recognition of the dying phase of life. Primary care interventions within EHCH framework could be augmented by this MDT approach for a more complex cohort of care home residents with severe frailty and greater co-morbidity profile including dementia.

Background

This clinical improvement project took place at a community frailty clinic. The primary and secondary care collaboration clinic comprised of an MDT including a physiotherapist, HCA, social prescriber, consultant geriatrician and GPwER in frailty. Older adults with a Rockwood score of 5 or more were assessed using the CGA domains. 

Introduction

Anticholinergic burden (ACB) is defined as the cumulative effect of taking one or more medications with anticholinergic effects (e.g. opioids, antimuscarinics and trycyclics). ACB score is a method of quantifying this. Higher ACB scores (3+) are associated with cognitive decline, risk of admissions with falls/ fractures and increased mortality.

The aim of the study was to quantify reduction in ACB score following structured medication review. The goal was to determine whether the frailty clinic was an appropriate setting for this.

Methods

Over a 5-month period the consultant geriatrician and GPwER calculated each patient’s ACB score. A medication reconciliation within their appointment facilitated deprescribing of high-risk medications. The HCA recorded ACB scores for all patients before and after medication review.

Results

54 patients attended the clinic. 18 patients had an initial ACB score of 0. The remaining 36 patients, had an ACB score of at least 1. Their mean reduction in ACB score was 1.2 points. Most pertinently, of the 19 patients with ACB scores of 3 or more, 12 left the clinic with a lower score and mean reduction was 2.1 points. One patient achieved a drop in score from 9 to 0.  Only 2 patients left with increased anticholinergic burden (in both cases, only increasin by 1 point).

Conclusions

Embedding the ACB score into the frailty clinics medication reviews were easily-achieved. This process is documented in clinic proformas, letters and the MDT discussion. This would be simple to transfer to similar settings.

Background: NICE Quality Standard (QS) 164 – QS1 states; Adults with Parkinson's have a point of contact with specialist services. This will facilitate continuity of care and access to information, advice, care and support when they need it. QS4 states; Adults with Parkinson's disease in hospital or a care home should take levodopa within 30 minutes of their individually prescribed administration time.

Introduction: To increase opportunities in meeting NICE QS’s consistently, Parkinson’s Specialist Nurses introduced Parkinson’s Champions. Individual studies consistently find that champions are important positive influences on implementation effectiveness. Over half of people with Parkinson’s don’t get their medications on time in hospital. This can cause stress, anxiety, immobility, severe tremors, and in some extreme cases death.

Method

Supportive structures that enabled the development and maintenance of our Champions Network:-

Clear Role Profile and Measurable Objectives

Provision of Resources/Tools

Ongoing Education/Training

Peer Support/Networking

Recognition/Appreciation 

PDNS leadership/support

Energy & Perseverance

Results: The Get it On Time Audit (GIOT) looked at Parkinson’s medications given more than 30 minutes early, on time and more than 30 minutes late. Following multiple interventions including promoting leadership and education within each dept, input to medicines policy, incident reporting and development of a learning module, On time medication administration improved from 58% to 80.05% compliance.

Champions were not experts in Parkinson’s when we started, through the process of undertaking the role, they have gained expertise and serve as an ongoing resource to their peers.

Conclusion: Our aim of having champions who enhance staff’s knowledge and skills so care delivered to persons with Parkinson’s is consistently safe and effective is being realised.

Investment in them, as demonstrated by audit results, is rewarded with more consistent meeting of NICE QS 164 and thus improved patient outcomes.

Our Champions network model will be shared with the Parkinson’s Excellence Network.

Introduction:

The geriatric population has a high incidence of dementia, delirium and frailty meaning often these patients cannot give comprehensive histories themselves. We are left with missing pieces of the puzzle; we might not know their ‘normal’ and frequently ask: ‘Are they always like this?’.

A collateral history becomes a valuable tool, contributing to a Comprehensive Geriatric Assessment and assisting the whole MDT to make informed decisions for patient-centred care.

The primary aim of this project was to improve the quality of collateral histories taken for patients admitted to the geriatric wards, with content measured against 8 domains. A secondary aim was to encourage timely collateral histories within 48 hours of admission to the ward.

Method:

Using PDSA methodology, collateral histories were analysed before and after implementation of a poster and teaching session.

Results:

At baseline each domain was covered a mean of 40.5% of the time (range 9% - 81%). Following intervention this increased by 22% to 62.5% (range 18% - 89%), demonstrating a significant improvement (paired t-test, P<0.05).

It was already common practice to take collateral histories within 48 hours of admission to the ward (91%) which was sustained post-intervention (88%).

Conclusion:

Use of a poster as a prompt, and delivering teaching, led to more thorough collateral histories. This suggests two barriers are knowing what to ask and perceived importance; elements which could be integrated into early postgraduate education. The impact on patient care has the potential to be significant and multidimensional but further work would be needed to understand this.

Background

Older people account for >40% of acute hospital admissions. Delivering alternatives to hospital admission and community-integrated care closer to home are increasing priorities. We aimed to develop an Emergency Department (ED) Frailty MDT to provide rapid assessment, early Comprehensive Geriatric Assessment (CGA), and reduce inpatient admission rates for frail older people.

Methods

From November 2023 to April 2024, a newly formed Royal Infirmary of Edinburgh ED Frailty team delivered CGA for older adults aged ≥75 (≥65 if care home resident) with Clinical Frailty Scores ≥5 in the ED. The ED Frailty Team consists of an Emergency Medicine Consultant with an interest in Frailty, a Consultant Geriatrician, two Frailty Advanced Nurse Practitioners, an Occupational Therapy Advanced Practitioner, Occupational Therapists and a HomeFirst Social worker. We prioritised patients who were most likely to achieve same-day discharge. We built on strong integrated community pathways including Hospital @ Home, Rapid Access Day Hospital, and Discharge2Assess. We evaluated efficacy and safety using readmission and mortality rates.

Results

We reviewed 344 patients and discharged 209/344 (60.7%) of frail older patients who were awaiting medical beds. We discharged 114/209 (54.5%) with Hospital @ Home; 49/209 (23.4%) with rapid access Day Hospital; 21/209 (10%) home with GP follow-up; 18/209 (8.6%) home with no follow-up; 5/209 (2.3%) home with other community follow-up; and 2/209 (1%) home with ambulatory care. Discharged patients had a 19.4% 30-day representation rate and a 5.8% 30-day mortality rate. Admissions from ED amongst Edinburgh city residents reduced from 60% to 43% in 75-85 year olds and from 52% to 46% in the 85+ age group.

Conclusion

ED Frailty MDTs can effectively deliver CGA in an Emergency Department setting, facilitating admission avoidance and delivery of integrated care closer to home that is effective and safe.