MDT

Background  

University Hospital Southampton (UHS) partnered with Saints Foundation (SF), to test the feasibility and acceptability of a non-registered Exercise Practitioner (EP) to work alongside the therapy team to promote physical activity (PA) of hospitalised older people. Our aim was to collect trust level data to review the impact the EP had on outcomes such as length of stay (LOS) and discharge destination (DD) and identify and address any additional challenges that arose. 

Methods  

The EP delivered twice weekly gym-based group interventions as well as regular 1:1 rehabilitation and education sessions to hospitalised older patients. Interventions were ward based or within the acute therapy gym.  

Results  

Between June and August 2023 the EP reviewed 82 patients, mean age of 88 years. 15 (18%) patients underwent 1:1 rehabilitation whereas 67 (82%) patients underwent gym-based rehabilitation sessions. Median LOS for patients reviewed by the EP was 15 days compared with average departmental LOS of 8 days. 53 (65%) patients were able to either maintain or improve their predicted to actual discharge destination, compared with 10 (12%) patients whose physical capability declined. Of those remaining, 1 patient died and 18 others had not yet been discharged. High patient satisfaction levels continued to be reported.  

Conclusion  

Intervention by a non-registered EP appears to have an impact on patients’ ability to maintain or improve level of function and physical dependency during acute hospital stay.  Factors such as outbreaks of infectious illness and staffing challenges prevented more frequent EP led intervention. Next steps include introducing daily class-based interventions. Participants will be encouraged to attend at least three classes. Anticipated benefits include improvement in patients’ functional levels and reductions in physical dependency on discharge.  Additional data will be collected on fear of falling and confidence in function as well as uptake of post discharge activity and readmission. 

Introduction. Pharmacists have traditionally worked in primary care, in the community, and with GPs. However, the role of the clinical pharmacist in primary care is evolving and there are plans to employ more clinical pharmacists in the NHS. With an ageing UK population, there is an increase in the number of people living with multiple long-term conditions, accompanied by polypharmacy, posing numerous challenges to healthcare systems. This review investigates the evidence about the varied roles and services delivered by clinical pharmacists in primary care, capturing the perspectives of health and care professionals, older adults, and their carers.

Method. Our scoping review followed the framework for scoping reviews in accordance with the Joanna Briggs Institute (JBI) methodology. A broad search was conducted in 2023 in CINAHL, Cochrane, Medline, SCOPUS, and Web of Science. We included articles that explored the landscape of clinical pharmacy services for older people in the UK, focusing on roles and services delivered, perceptions, and experiences.

Results. A total of 23 articles was included. These shed light on the multifaceted responsibilities of clinical pharmacists for older people. Stakeholder perspectives, including healthcare professionals and care home staff, emphasise the positive outcomes of clinical pharmacist involvement, from reducing other practitioners’ workloads to improving patient safety. However, communication gaps amongst the primary care team and those living with dementia, concerns about competence, and the need for clear role definitions of clinical pharmacists emerge as challenges.

Conclusions and implications. The review enhances our understanding of the clinical pharmacist service in the UK and identifies gaps in research evidence, emphasising the need for empirical studies on the experiences of older people with cognitive impairment and those from minority ethnic backgrounds. The findings can be used for policymaking, workforce planning, and healthcare provision to improve the services for older people in the UK.

Introduction

Surgical intervention may not be appropriate in frail patients with new or recurrent bladder cancer. To ensure that their care is aligned to the principles of ‘Realistic Medicine’, we developed a structured programme of joint management between our Peri-Operative care of Older People undergoing Surgery (POPS), Anaesthetic and Urology teams. This analysis examines our experience.

Method

Patients listed for surgery and deemed to be frail at initial screening, underwent Comprehensive Geriatric Assessment, an anaesthetic review (if indicated) and surgical evaluations. Validated measures of frailty, cognition and function were used. Each patient had a joint consultation with a bladder cancer and POPS specialist. Patient details, clinical metrics were recorded prospectively on a POPS database, with clinical follow-up records maintained electronically.

Results

From a total of (approximately) 460 suspected or confirmed bladder cancer patients, 100 were reviewed in the joint POPS-bladder cancer specialist clinic between January 2017 and early January 2024. Moderate/severe frailty was noted in 55%. Only 23% of patients proceeded with their intended surgery (GA cystoscopy/TURBT/cystectomy). Most patients opted for no operative intervention instead choosing best supportive care (45%), repeat flexible cystoscopy (17%) or repeat diagnostics (14%). Over the follow up period (median 4 years), of those who opted for no operative intervention, most did not need to change from the recommended plan; 5% of patients required an emergency admission (bladder washouts only).

Conclusions

This novel joint working with POPS and bladder cancer specialists appears to be a safe, comprehensive, and patient-centred approach to the effective and efficient management of frail patients with bladder cancer. It allows various important factors to be carefully considered and balanced including frailty, patient priorities, symptom burden and tumour size/grade/number. This model of care means selected patients could avoid the burden of unnecessary procedures and surveillance.

1. INTRODUCTION: Older adults, particularly those with multi-morbidity, frailty or cognitive impairment, are under-represented in clinical research studies. To facilitate inclusive research for this population requires empowerment of all members of the multi-disciplinary team to promote and advocate for this underserved population. However, understanding of the personal and organisational barriers to staff engagement with research within Elderly Care remains limited.

2. METHOD: Using an amended version of the research capacity and culture tool an anonymous online survey open all staff members of an Elderly Care Department (n=351) in a District General Hospital was undertaken. The survey results were used to inform the departmental 5-year research strategy and launch a multifaceted educational and engagement programme.

3. RESULTS: 107 responses to the survey were received with a wide multi-disciplinary contribution. Despite 89% of respondents stating research was not part of their job, 96% were willing to be more involved in research. Motivators to staff engagement in research included: dedicated time for research (74%), research skills training (73%), mentors (67%), research relevant to elderly care (62%), hearing from researchers within the department (54%) and local promotion of research studies (49%). Barriers to research included: lack of time (78%), unsure of opportunities (65%) and lack of skills (47%). As a result of the survey numerous departmental interventions have been staged: a multi-disciplinary research half day, research opportunity display boards, monthly departmental presentations, promotion of the associate Principal Investigator scheme, Q&A webinars and a section in quarterly newsletter.

4. CONCLUSION(S): Multi-disciplinary staff working within Elderly Care can be motivated to advocate and engage with research opportunities for older adults. Supporting their engagement through the provision of dedicated time, research skills training and promotion of opportunities is key.

East Kent has 38,101 people over 80 years, 39, 021 living with moderate or severe frailty and 304 care homes. This population have high levels of unplanned admissions which can put them at risk of long hospital stays, reduced mobility and increased delirium.

East Kent Ambulance services (SECAMB), Acute hospitals (EKHUFT) and Community Services (KCHFT) have piloted a single-point of access consisting of an ED consultant, community frailty clinician, Urgent care senior nurse, advanced paramedic practitioners. They sit together at the ambulance bases, 10am-6pm Monday to Fridays. This team reviews all patients awaiting ambulances to assess whether there are alternative services to ED which would meet the individuals' needs.

Method

The MDT assesses all patients listed as awaiting an emergency ambulance. Clinical records can be accessed from all services including GP records. If patients would benefit from treatment by alternative services, rather than conveyance, the paramedics are asked to call the MDT. This allows clinical assessment, history and investigation results to be taken into account in planning care. Patients and Carers are involved in deciding how they would like to receive medical care via a video or phone link with clinicians.

Results

Conveyance to hospital pre pilot - 62% post pilot less than 50%

Ashford catchment: admissions save weekly 27.3, bed days saved weekly 179.2

Thanet Catchment: admissions saved weekly 19.1, bed days save weekly 106.9

Conclusion

Many people can be treated effectively without conveyance to hospital through pre-hospital triage, consultation and planning by senior clinicians in a multi-disciplinary team.

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:

Malnutrition is a significant problem in the hospitalised population, particularly in those with cognitive impairment. Malnutrition has been shown to increase rates of infection, pressure sores, length of stay, readmission and morbidity. Malnutrition Universal Screening Tool (MUST) scoring identifies adults at risk of malnutrition and prompts dietetic referrals where appropriate. MUST score recordings across four Complex Medicine Units in the John Radcliffe Hospital were often inaccurate or incomplete, impacting on the identification of malnutrition and timely referral to dietetics. Multi-disciplinary teaching on MUST scores improved identification of malnutrition in this patient population. Further interventions are planned.

Methods:

Electronic patient records for patients >/=75 years of age admitted to the Complex Medical Units at the John Radcliffe Hospital with a diagnosis of cognitive impairment were analysed. The percentage of patients who had either an incomplete or incorrect MUST score were identified. The percentage of patients that did not receive a referral to dietetics due to an underestimated MUST score and the reasons for the underestimation, were determined. Multi-disciplinary teaching interventions focussing on the identification of malnutrition in inpatients were implemented. MUST score recording was re-analysed following intervention.

Results:

71% of MUST scores underestimated risk of malnutrition. 67% of this cohort met criteria for referral to dietetics based on a corrected score, with only 33% of this group receiving the appropriate referral. Failure to identify weight loss in the preceding 3-6 months accounted for 88% of inaccurate scores. Multi-disciplinary teaching interventions improved MUST score accuracy by 14%, indicating improved identification of malnutrition risk.

Conclusion:

Identification of malnutrition is important to improve patient outcomes. Changes to practise will include multi-disciplinary education, improved use of technology to generate accurate MUST scores and the utilisation of transfer boards with integrated weighing scales to ensure all new admissions have an accurate weight.

Introduction

We proactively reviewed nursing home residents using a multidisciplinary team (MDT) approach within a Primary Care Network (PCN). We aimed to enhance care coordination, reduce inappropriate medication use and ensure all residents had current advanced care plans in place.

Method

An MDT comprising a geriatrician, prescribing pharmacist, general practitioner, and nurse reviewed residents proactively. This involved reviewing the residents' current health and care needs, falls risk, medication regimens and advance care plans. We then performed medication reviews, reviewed advanced care plans, and identified the need for further interventions. When we repeated the process, we used a proforma that could be pre-populated prior to the meeting by the pharmacist and geriatrician to improve efficiency of the discussion.

Results

The initiative was piloted in two residential nursing homes with a total of 65 residents reviewed, of which 86% (n=56) received interventions. There was a 47% (n=29) increase in completed advanced care plans. 62% (n=40) of residents had medicines optimised, with polypharmacy being reduced in 46% (n=30) by an average of 2 medications per resident. 8% (n=5) were referred to additional services and 8% (n=5) required further investigations.

Conclusion(s)

This proactive MDT model effectively addressed the needs of residents whilst demonstrating immediate positive outcomes. Key facilitators to good practice were teamwork, clarifying the objectives of the MDT, prior reviews of patient records, and ensuring staff who knew the residents well were present. We will use this approach with other nursing homes within the PCN and share our results with colleagues. This has the potential to reduce costs of medications and hospital admissions, as well as improve quality.

In 2022 we had a unique opportunity to develop a Geriatric service in Totnes Community Hospital after a long-standing GP led service provision ended. Given the fact that the majority of patients in the Community Hospitals were over the age of 65 and many had multiple co-morbidities or presented with a frailty syndrome, it was felt that the Geriatric department was the most suitable specialty to take over the service provision. Method Over a period of 12 months, we have gradually introduced key aspects from the Comprehensive Geriatric Assessment (CGA) to the care of our patients. Every new patient had a CGA on admission, completed by the clerking doctor with support from the MDT. We have concentrated on identifying and managing falls risk, bowel and bladder care, bone protection assessment and reviewing inappropriate polypharmacy. Through collaboration with our community pharmacist and nursing staff we have introduced additional medication administration services to include intravenous bisphosphonates, monofer infusions, medical hyperkalaemia management and intravenous electrolyte replacements. For our frailer patients we looked at prioritising care in the community, and closer to their home and family. Where appropriate and safe, we kept the patients in the community hospital for both acute illness and end-of-life care, instead of re-admitting them back to the acute hospital. Conclusion Over the year we have trained, upskilled and supported our nursing staff in managing and treating more acutely unwell and complex patients, so that we can provide more comprehensive and holistic care to our frailer patients in a community setting. We have prevented numerous re-admissions back to the acute hospital by being able to provide increased level of medical care. This was particularly important for the many patients with advanced dementia and delirium. The current model of care is still ongoing and continuing to develop.

Introduction:

Frailty significantly affects outcomes like length of stay and readmissions in elderly patients. At Queen Alexandra Hospital, inpatients under 85 are under the care of General Internal Medicine (GIM) wards and they lack regular access to frailty services. This baseline audit evaluated frailty assessment, management practices and patient outcomes, implementing staff education, ward posters, and a frailty Multidisciplinary Team (MDT) between cycles.

Methods:

Data were retrospectively collected from three GIM wards over two cycles—January and August 2024. Eligibility criteria: Patients aged 65-85, admitted to GIM were included. The audit measured frailty assessment using the Clinical Frailty Scale (CFS), Comprehensive Geriatric Assessment (CGA) practices, frailty prevalence (CFS ≥ 5), advance care planning (ACP), and readmission rates.

Results:

Frailty assessment compliance rose from 76.6% to 94.4%. Frailty detection (CFS ≥ 5) increased from 36% to 75%. CFS documentation improved to 34.5%, with better CGA documentation. However, ACP rates remained low at 3.03%, and 56.6% of frail patients were readmitted within the year, indicating ongoing challenges. Conclusion: Improvements were seen in frailty assessments and detection, yet ACP remains underutilized, and readmission rates are high. Continued efforts are needed to enhance ACP documentation and frailty management strategies.

Recommendations:

1. Implement robust policies for ACP and implement a straightforward pathway for ACP documentation by all doctors.
2. Educate all doctors to practice comprehensive geriatric assessment and participate in frailty MDT meetings.
3. Further audits to specifically investigate the proportion of patients admitted with frailty syndrome and assess their prognosis.
4. Prioritize triage based on CFS scores/frailty over age to enhance targeted care and resource allocation.