MDT

BACKGROUND:

At Sheffield Teaching Hospitals, an Older Surgical Patients Pathway (OSPP) began in 2014, introducing a Consultant Geriatrician working in a liaison role within General Surgery.

BGS reports in its 'Case for more Geriatricians' that the number of people aged over 85 is set to double by 2045. An increase in patient age and complexity is already being seen across a range of services including admissions to general surgery.
We look to characterise this increase to make the case for an expansion of the OSPP service.

METHODS:

1. We identified patients aged over 75 admitted under General Surgery in July to December of 2014 and 2023.

2. We analysed these patients for their 30 day mortality, theatre episodes, length of stay and Hospital Frailty Risk Score (an automatic calculation from hospital records using a weighted count of frailty- related diagnoses).

RESULTS:

The number patients aged over 75 admitted in the 6 months from July to December has increased from 646 in 2014 to 847 in 2023.

The increase in this age group is associated with an increase in the number of patients with a hospital frailty score greater than 20 (from 18 to 69) and those with a length of stay longer than 15 days (from 93 to 124).

Additionally, between 2014 and 2023 patients aged over 75 had an increase in total theatre episodes (from 107 to 125) and 30 day mortality (from 48 to 63).

We propose that this increase in number and complexity of older patients supports the expansion of OSPP Service, for example by the addition of a ST3+ level doctor.

Introduction

Advance care planning (ACP) offers people the opportunity to plan their future care whilst they have capacity to do so and is supported by national guidance. Decisions regarding future care are more likely to be individualised and holistic when patients and their significant others are involved. This QI project aimed to address this by increasing the frequency of ACP discussions being offered and recorded on gerontology wards in an acute London Trust.

Method

A multi-professional steering group was established to improve ACP using PDSA methodology. A new ACP toolkit, training programme and electronic flowsheet (within the hospital’s patient record system) were implemented. ACP documentation quality was audited on gerontology wards pre and post implementation (over one to four months respectively). Data was compared using Pearson’s Chi-squared test.

Results

ACP flowsheets were completed by junior and senior doctors, and clinical nurse specialists in frailty and palliative medicine. The initial audit found disparity between documented topics of ACP conversations, with cardiopulmonary resuscitation recommendations being most discussed. Post implementation, 24 ACP flowsheets were reviewed, showing that more ACP topics were documented where these conversations were had; preferred place of death increased from 24% to 60% (p 0.011); treatment escalation plan increased from 41% to 75% (p 0.014); preferred place of care increased from 59% to 71% (p 0.066). Topics not showing significant improvement in documentation (despite inclusion in the flowsheet) were spiritual needs, information needs and prognostic discussion, broader social needs and what was most important to the patient.

Conclusion

The implementation of an electronic ACP flowsheet improved documented ACP conversations in some topics, guiding healthcare professionals to deliver care that aligns with peoples’ wishes and preferences. Documented conversations became easier to access, review and audit. Work is still needed to promote ACP conversations being centralised around what matters most to patients.

The commonest nosocomial infection in the UK is Hospital Acquired Pneumonia (HAP), associated with prolonged length of stay and mortality. The HAP incidence on Elderly care wards was > 5% of admissions, exceeding the national average. An initiative ‘Mind the HAP’ was launched which included doctors, nurses, pharmacists, SLTs, physiotherapists and coders to improve HAP diagnosis, management and prevention. Methods: To monitor the effectiveness of the interventions 3 audit cycles were performed between 2019 and 2023. Several interventions were implemented between 2019 - 2023.A multidisciplinary steering committee was formed with 3 work streams (diagnosis, management and prevention). To improve the accuracy of diagnosis and management of HAP, focused educational sessions were conducted for junior doctors with monthly meetings with coders. Nurses championed implementing the HAP prevention strategies i.e. hand hygiene, mouth care and positioning at 30-45 degrees. Regular comprehensive training sessions were held. HAP awareness and education campaign was launched. Daily nursing huddles helped to identify high risk patients. Physiotherapists provide chest physiotherapy to yield sputum sample collection among pneumonia patients. An electronic dashboard of incidence of HAP against the preventative measures and sputum culture reports has been launched with help from informatics. Information leaflets on HAP were created for patient awareness. An electronic HAP power plan to facilitate diagnosis and management of HAP will be launched from February 2024. Results: HAP incidence has dropped to < 2 %, diagnostic accuracy improved from 35% to 81%, and sputum collection has increased from 9% to 24%. The HAP Quality Improvement Project received first prize for the most impactful Quality Improvement initiative at the Trust-wide conference in 2023. The results have been shared with the regional Microbiologists. The collaborative efforts coupled with effective leadership and guidance, have been pivotal to the success of "Mind the HAP" project.

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.

Background: ‘IN REACH’ was established, having identified a significant need to improve nutrition for cognitively and physically frail hospital inpatients, admitted to the Complex Medical Units (CMU) at the John Radcliffe Hospital. The IN REACH team includes the CMU multi-disciplinary team (MDT), representatives from patient and volunteer groups, caterers and medical illustrators.

Introduction: IN REACH identified that food and drink is often unreachable by inpatients. The project’s aim is to ensure food and drink is always within patient reach, improving nutritional intake, avoiding dehydration, reducing weight loss, reducing family anxiety, promoting independence and improving health outcomes.

Method: MDT members, patients and their families were engaged in the design. Baseline observational data included whether both food and drink were in reach and whether the patient had cognitive impairment. Interventions to be evaluated by Plan-Do-Study-Act (PDSA) methodology include: raising awareness at daily MDT meetings; focussed education by presenting observational data to catering team; involvement of volunteers; the introduction of IN REACH champions; and prompting by signage, both physical and digital. Improved inpatient nutrition will be correlated with data on length of stay and health outcomes. Improved rates of return to baseline function and independence are anticipated, by keeping food and drink, in reach.

Results: Baseline data showed out of 319 inpatients, only 33% had both food and drink within reach. 67% had cognitive impairment and only 27% were able to reach food and drink. Following 4 initial PDSA cycles 58% of patients had food and drink within reach.

Conclusions: Most CMU patients have food and drink left out of reach. Patients with cognitive impairment are particularly at risk. Changing ward culture is challenging. Further and repeated interventions are necessary.

Purpose

To investigate physiotherapists’ perspectives of effective community provision following hip fracture.

Methods

Qualitative semi-structured interviews were conducted with 17 community physiotherapists across England. Thematic analysis drawing on the Theoretical Domains Framework identified barriers and facilitators to implementation of effective provision. Interviews were complemented by process mapping community provision in one London borough, to identify points of care where suggested interventions are in place and/or could be implemented.

Results

Four themes were identified: ineffective coordination of care systems, ineffective patient stratification, insufficient staff recruitment and retention approaches and inhibitory fear avoidance behaviours. To enhance care coordination, participants suggested improving access to social services and occupational therapists, maximising multidisciplinary communication through online notation, extended physiotherapy roles, orthopaedic-specific roles and seven-day working. Participants advised the importance of stratifying patients on receipt of referrals, at assessment and into appropriately matched interventions. To mitigate insufficient staff recruitment and retention, participants proposed return-to-practice streams, apprenticeship schemes, university engagement, combined acute-community rotations and improving job description advertisements. To reduce effects of fear avoidance behaviour on rehabilitation, participants proposed the use of patient-specific goals, patient and carer education, staff education in psychological strategies or community psychologist access. Process mapping of one London borough identified points of care where suggested interventions to overcome barriers were in place and/or could be implemented.

Conclusion

Physiotherapists propose that effective provision of community physiotherapy following hip fracture could be improved by refining care coordination, utilising stratification techniques, employing enhanced recruitment and retainment strategies and addressing fear avoidance behaviours.

At University Hospital Monklands, a district general hospital in Lanarkshire, an ED in-reach pilot was set up to deliver the best possible outcomes for frail older adults by proactively reducing unscheduled admissions, thereby reducing the time they spend in the hospital.

Aim

To reduce unscheduled admissions for patients with a clinical frailty score (CFS) ≥ 6, admitted to ED between 8am – 3pm, Monday to Friday, by 50%. Method An ED Frailty MDT was formed, comprising of Acute Care of the Elderly (ACE) nurses/ Advanced Nurse Practitioners (ANP) and Consultant Geriatricians. Patients ≥ 65 years with a CFS ≥ 6 likely to be discharged on the same/next day were identified by ED staff and referred to ANP/ACE nurses. A Comprehensive Geriatric Assessment (CGA) was performed by the nursing team within 30 minutes of the referral, with the support of the consultant geriatrician. Data was collected on number of patients seen, time taken before review and patient outcomes.

Results

97 patients were reviewed at the ED by the team within a 4 – month period (October 2023 – January 2024). 53.6% (52/97) of them were discharged, either directly home(32) or with a referral to the Hospital at Home service/Home Assessment Team (20).

Conclusion

The pilot had three tests of change with variable results. The volume of calls from ED staff improved after the first and second tests of change (which involved increasing visibility of the ANP/ACE nurses in ED and having the consultants accompany them for reviews respectively) but a sharp drop was noted after the third test of change. There was also the challenge of staff shortages but despite this, the pilot was well received by the managers and staff in ED and further work is being planned on how to establish the gains of the project.

INTRODUCTION: Guidance around optimal management of patients with cognitive impairment within a Parkinson’s disease (PD) multidisciplinary team (MDT) is lacking. This project aimed to improve the service pathway by integrating a Parkinson’s disease specialist psychiatrist (PDSP) within the MDT rather than referring patients to a separate mental health service.

METHODS: Data including mental health symptoms, time to review, diagnosis, treatment, and follow-up were collected over 12 months from the electronic clinical records of all patients referred to the PDSP with cognitive impairment. This data set was subject to descriptive analysis and economic evaluations.

RESULTS: 47 patients with Parkinson’s and cognitive impairment were referred to the PDSP - median waiting time to review was one month. Fourteen patients were diagnosed with mild cognitive impairment, 5 with dementia, and 28 with another condition or requiring further diagnostic assessment. Review with the PDSP prevented onward referral to another service in 29 cases, saving an estimated £1140 and reducing duplication of assessments.

CONCLUSIONS: Integration of a PDSP into a PD MDT avoided the need to refer the majority of patients to a separate mental health service, led to fewer health care professional contacts, reduced duplication, and cost savings. It is likely that the model led to earlier diagnoses and treatment. Evidence as to patient and carer experience is not yet available.

Introduction: Effective board rounds improve the patient’s experience and reduce the risks associated with a prolonged hospital stay. Ward C54 at Queen’s Medical Centre is a 30-bedded ward dedicated to the provision of care for older, frail (CFS ≥ 6) patients. Board round on C54 was unstructured and could take over an hour. The project team set out to reduce the duration of board round, improve the quality of information handed over and improve staff satisfaction with board round. 

Method: Pre- and post-intervention data on the daily duration of board round were collected by the junior doctors on the ward. PDSA methodology was then used to test the following interventions: 1. Nerve centre updated daily by the junior doctor responsible for that bay 2. Junior doctors to present information using 4Q approach 3. Staff nurse in each bay highlighting any issues for that bay. Pre- and post-intervention surveys were also distributed to staff working on C54. 

Results: The duration of board round was reduced from an average of 52 minutes to an average of 38 minutes post-intervention. Over 90% of survey respondents believed the board round to be more efficient and over 80% were either satisfied or very satisfied with board round duration. 

Conclusions: The findings have shown it is possible to improve the duration of and staff satisfaction with board round by giving MDT members a framework to help structure handover of written and verbal information. Future considerations include providing teaching sessions to staff on the board round process. 

Introduction

Little is known about how Health Care Professionals (HCPs) conducting Comprehensive Geriatric Assessment (CGA) assess spiritual needs.  

The aim of this study was to better understand how UK HCPs understand and incorporate assessment of spirituality into CGA for community dwelling frail older people.

Methods

Semi-structured interviews were undertaken with HCPs who regularly undertake CGA in the community as well as Anna Chaplains (ACs) whose remit is to provide chaplaincy to community dwelling older people. An inductive approach was taken using a topic guide to structure the interviews.  Thematic analysis was undertaken using NVIVO. Ethics approval was granted through St Augustine’s College of Theology.

Results

Three HCPs and two ACs were interviewed. Three themes emerged.

Firstly, that spiritual assessment needs time, trust and skill and cannot be established using checklists. Assessment hinges on building a rapport between the patient and HCP. HCPs and ACs suggested potential questions that could support assessment of spiritual needs.  Secondly, supporting spirituality is focused on sustaining identity, fostering hope and encouraging spiritual growth.  Finally, health care professionals lacked confidence and understanding in how to recognise and meet spiritual needs. Several suggestions were made as to how to address this. 

Key conclusion

All participants agreed that incorporating assessment of spirituality into CGA was important but that doing so effectively requires understanding and skill. The questions suggested by participants mapped well onto existing models of spirituality in ageing and frailty. Study findings could be used to develop training for HCPs undertaking CGA.