MDT

Background:

An estimated 10% >65-year-olds and 25-50% >85-year-olds live with frailty in the UK, ¹ making up a greater proportion of surgical caseloads. Perioperatively, frailty is an independent risk factor for adverse outcomes.^2,1  Timely recognition and assessment is vital in prevention, however, awareness of frailty and the Clinical Frailty Scale³ (CFS) is limited amongst clinicians.⁴

Methods:

A survey was completed by doctors of all grades across surgical specialties in Sandwell General Hospital. Questions explored recognition of frailty, use of CFS, and their influence in perioperative decision making.

Results:

A total of 33 Doctors completed the survey (33.3% Junior Doctors). Whilst 97% believed they look after frail patients, 69.7% were aware of the CSF but only 30.3% had used the scale.

All doctors thought frailty plays a role in their decision making post-operatively, however >87% rated their confidence in recognising frailty ≤3/5.

Key Messages:

Across all grades, there is an awareness of the importance of frailty, however a lack of confidence in its recognition. Need for further education is evident, particularly regarding the CFS. In this respect, focused education sessions are being implemented for all grades of doctors to consolidate knowledge and facilitate a multidisciplinary approach to decision making in surgery

Introduction: Frailty is under-recognised in hospital leading to unwarranted variation in care. National guidance recommends that all healthcare professionals can identify frailty and offer interventions to reduce risk factors for frailty. Previously, physiotherapists working in Older People’s Medicine (OPM) did not record frailty status in their clinical assessment. This quality improvement project seeks to translate and implement best practice, supporting physiotherapists to record the Clinical Frailty Scale (CFS) score within routine patient assessment, so interventions can be initiated to optimise outcomes.

Project aim: Within 3 months, to achieve a 50% increase in the number of patients with a Clinical Frailty Scale (CFS) score recorded within their physiotherapy assessment.

Methods: Plan-Do-Study-Act cycles with interventions of bespoke teaching and assessment proforma re-design were employed targeting the OPM physiotherapy team on ward 31, RVI.

Measures: The weekly number of patients with a CFS score recorded within physiotherapy assessment was collected over 13 weeks and evaluated on a run chart. Staff knowledge and skills self-assessment scores and cohort data were also recorded and described using descriptive statistics.

Results: At baseline – 0/114 (0%) physiotherapy patients had a CFS score recorded, this improved to 95/192 (49%), suggestive of effective change post interventions. Staff confidence scores also improved.

Conclusions: This project has led to improved frailty awareness and identification amongst OPM physiotherapy staff. This work supports a collaborative approach to improving frailty care; better identification of frailty can reduce harm by informing healthcare needs, supporting patient flow, and resulting in better, safer, and more equitable care.

Introduction

The Covid19 pandemic represents an unprecedented challenge to global health and care services and necessitated a rapid shift towards healthcare being provided remotely.¹ A quality improvement project was conducted in Cardiff CRT to improve staff confidence in relation to remote-working to optimise the care of older patients in the community.

Objectives

• To integrate the use of technology in intermediate care in Cardiff CRT

Method

A survey was sent to Cardiff CRT staff in May 2020. The plan-do-study-act (PDSA) model was used to implement improvement interventions whilst allowing continuous service delivery. These included investment in hardware, updated software, a daily team huddle, increased transparency throughout the Multidisciplinary Team and stricter referral criteria. A follow-up survey was conducted in February 2022.

Results

Three key areas for improvement were identified: i) access to resources ii) team communication and iii) access to information.

The majority of respondents (62%) had no experience of remote-working prior to the Covid19 pandemic. Now, telephone consultation (50%), video consultation (19%), email (23%) and other technology (8%) are regularly employed. Self-reported confidence has improved in relation to remote-working.

Most respondents (56%) reported improved time-management and flexible working (30%) as the primary advantages of remote-working. Isolation from team members (44%) and barriers to communication (44%) were cited as the main disadvantages. 75% of respondents anticipate changing the way they work due to skills learnt during remote-working. Job satisfaction is now lower, however many recognised this was due to pandemic sequelae and other extraneous factors.

Conclusion

• Majority of staff have learnt additional skills and improved confidence in remote-working
• All staff now employ remote-working in Cardiff CRT and most plan to continue post-pandemic
• Further training needs have been identified in the virtual intermediate care setting
• Team communication and isolation remain an issue
• Job satisfaction has declined during the pandemic

References

¹ Nuffield Trust

Disclosure of interests: None

Key Words:

Covid19, Frailty, Older People, Community, Intermediate Care, Technology

Introduction Whitehills Health and Community Care Centre (WHCCC) is a 31-bed community hospital. Weekly multidisciplinary team (MDT) meetings occur to co-ordinate care and discharge planning. The format prior to this quality improvement project was meetings twice per week using Microsoft Teams. Errors were noted such as incorrect discharge dates and missed referrals. Aims: improving information transfer during MDT meetings, reducing errors in communication, reducing meeting duration and improving staff satisfaction. Methods Data was collected in the format of surveys distributed to members of the MDT and meeting duration . There were three PDSA cycles: Introduction of chairperson and proforma Chairperson, Proforma and screensharing on Microsoft Teams Reduction of MDT meetings to once weekly Results The initial survey found that 43% (n = 3/7) of staff found meetings to be effective. One hundred percent noted that information had been missed or not acted upon (n = 7). This improved with each cycle; cycle 3 data showed that 100% felt the meetings were effective and only 14% felt information was missed (n=1/7). Given the improvements, cycle 3 trialed a once weekly meeting. Average weekly time spent in meetings fell from 213 minutes to 130 minutes (39% reduction). 100% (n=7) said they were very satisfied or somewhat satisfied with the once weekly MDT. Conclusions Creating a standardised structure in the form of chaired meetings and MDT proforma was found to improve effectiveness of the meeting and reduce errors. These changes allowed a more efficient and safe once-weekly meeting. This led to reduction in time away from clinical areas for MDT members. These changes have been adopted and maintained by the WHCCC team. Areas of future development may include: The impact of blended or face to face meetings and further reduction in meeting times.

Introduction: Scotland's National Dementia strategy (2017) highlights the need to improve identification and management of dementia. Hospital at Home (H@H) teams often identify undiagnosed cognitive decline as part of comprehensive geriatric assessment. A trainee ANP in dementia services was appointed in 2019 in West Lothian; before this, the average waiting time to memory clinic assessment was 6 months for a home visit, and 12 months for outpatient clinic review. Affiliated with REACT H@H, the ANP identified a significant unmet need for assessment of cognitive decline in a patient cohort referred to H@H.

Method: Baseline data from patients reviewed by the dementia ANP was collected between Sept 2021 – Feb 2022, including referrals from H@H. A new pathway was then introduced to streamline referrals including education and upskilling of the H@H team. Further data was collected between Sept 2022 – February 2023.

Results: In the first cohort, 161 patients were assessed by the Dementia ANP, of which 39 (24%) had been referred from H@H. 60 patients (37%) were seen as a home visit, and 101 (63%) in clinic. 2 (1%) of referrals were managed with advice only. 125 patients (78%) were given a diagnosis of dementia; other diagnoses included delirium, low mood and anxiety. In the second cohort, 168 patients were assessed by the Dementia ANP, 39 (23%) being referred from H@H. 94 (56%) were seen in clinic and 74 (44%) as home visits. 10 (6%) of referrals were managed with advice only. 138 (82%) were given a diagnosis of dementia. Time to diagnosis assessment of dementia was reduced to 1 month for home assessment, and to 4 months for outpatient clinic assessment.

Conclusion Appointment of a Dementia ANP and integration with H@H  services improves time to assessment and diagnosis of dementia. 

Introduction:

Nationally, there have been increased attendances to hospital for older frailer adults. Recommendations from GIRFT and NHS England acknowledge the importance of identifying frailty, and the role that dedicated specialist services play. Best practice indicates when frailer adults receive a Comprehensive Geriatric Assessment (CGA), this reduces patient harm and improves outcomes.

Locally in October 2022, Bolton NHS Trust converted an Acute Medical Assessment Unit (AMU) to a 22 bedded frailty unit, the Older Person’s Assessment Unit (OPAU) to provide older frailer adults with early specialist input and review from a dedicated multi-disciplinary team (MDT). The unit is run by three Consultant Geriatricians and a dedicated wider MDT, with links to community partners and when needed preferential admission to Geriatric base wards.

Methods:

Data was collated and analysed with set metrics by the Trust’s Business Intelligence Department. Data was compared for the 3 months pre and post inception of the frailty unit. Regular service reviews occur and utilise PDSA cycles to assess interventional change.

Results:

The average age of patients pre-intervention was 69, and post intervention was 79.6.

Pre-intervention, the average length of stay for patients admitted from AMU to Geriatric base wards was 25.93 days. This reduced to 18.79 days post-intervention.

The average length of stay for patients admitted to non-Geriatric base wards was 10.77 days, this reduced to 8.62 days post intervention.

Conclusion:

Specialist Consultant Geriatrician and MDT input on a dedicated frailty unit has reduced the average length of stay of patients to all base medical wards assessed, especially base Geriatric wards. This has clear implications on patient flow, and benefits patients and the Trust. We expect this will have a compound and positive effect on patients by reducing the risk of deconditioning and potential development of inpatient harms.

Introduction

About 300,000 people living with Frailty undergo operations annually. Current evidence suggests that comprehensive geriatric assessment (CGA) pre-operatively enhances shared decision making (SDM), equity of access to surgery, length of stay (LOS) and mortality. Multiple NCEPOD reports, the National Emergency Laparotomy Audit (NELA) and National Hip Fracture Database (NHFD) programs have highlighted the unmet need in caring for these patients. Our aim was to introduce a novel combined Geriatrician/Anaesthetist pre-assessment clinic to provide better SDM and perioperative optimisation to improve outcomes for elective colorectal surgery.

Method

We performed combined CGA and Anaesthetic pre-operative assessment in patients undergoing elective colorectal surgery aged ≥65 years between July 2021 to August 2022. Data including Clinical Frailty Score (CFS), LOS, Type of surgery, P-POSSUM Score, 30-day mortality and 90-Day mortality were analysed.

Results

We reviewed 48 patients in 14 months. 69% patients underwent surgery and 27% declined after a comprehensive SDM process. The median age of operated patients was 80 (65-94) compared with 74 in 2020-21. 58% of patients operated were over 80, compared to 24% in 2020-21, prior to clinic inception. The median CFS was 4. 55% of patients had a LOS ≤7days (73% in 2020-21), 32% was 8-14days (18%) and 13% was >14days in hospital (9%) respectively. 32% had a P-POSSUM score of ≥5% whereas 10% had a score of >15%. The overall 30-day and 90-day mortality rates for our cohort was 0%, compared with 0% and 3% respectively in 2020-21.

Conclusion

Our data suggests that our clinic has enhanced equity of access to curative colorectal cancer surgery for older adults. 90 days mortality remained 0% owing to excellent patient selection and enhanced perioperative care. Importantly, 27% of patients declined surgery after an extensive process of SDM. Further work needs to be completed assessing decision regret and satisfaction with SDM (SDMQ9).

Background Prehabilitation in clinical trials improves fitness, improves quality of life, reduces complications, and reduces hospital length of stay It is not standard of care in routine clinical practice. This prospective observational study reports the outcomes of a clinical AHP prehabilitation service for older people undergoing major cancer surgery. Methods The LUHFT Prehab service commenced in August 2017, patients prior to major abdominal surgery for cancer were eligible for referral, this was inclusive of 8 different surgical specialties. Referred patients were invited to attend a multi-disciplinary prehabilitation clinic inclusive of physiotherapy, occupational therapy and dietetic support. In a review of the past 12 months clinical frailty score was recorded at baseline and pre surgery. Patients were given individualised exercise, wellbeing, and nutrition plans, and provided with support via 121 or group based follow up. Where distance was a barrier, telephone clinics were undertaken. Results Over a 12-month period 477 patients were referred over the age of 65, of these 436 underwent baseline frailty assessment. Of these 380 went on to have surgery with an average period of 40 days between initial prehab assessment and their elective admission. In these patients 50 scored 5 or above on the clinical frailty scale, 105 fell within the vulnerable category and 163 in managing well at baseline. Of those patients reassessed pre surgery 100% of patients with a frailty score of 5 or above either improved or maintained their score. Of those that scored a frailty score of 4, 94% either improved or maintained their score. Conclusion A prehabilitation service is feasible and improves frailty in the lead up to major abdominal elective surgery in a cohort that would otherwise be expected to decondition due to the nature of their disease. Prehabilitation should be part of standard care for older patients undergoing cancer surgery.

Introduction

Despite recognition of the status of gerontological nursing as a speciality , there is no specific UK competency framework for early career nurses working with older people. As part of a feasibility intervention to improve recruitment and retention of nurses within the speciality (ECHO Early Careers in Healthcare of Older People and PEACH Programme for early careers for care home nurses) , we developed a bespoke competency framework appropriate for nurse working within all sectors.

Method

The national and international literature on published competency frameworks was reviewed to identify core domains of knowledge and skill. We integrated these within a CGA model to develop a draft competency framework which we then tested for face and content validity. It was reviewed by expert practitioners and managers from NHS and care home providers, and a national reference group (British Geriatrics Society Nurse Special interest group). It was then implemented by students under taking the ECHO and PEACH programmes. A mixed-methods approach was used involving online surveys, one-to-one interviews and focus group interviews with students, mentors, ward managers and care home managers. Ethical approval was obtained from the university ethics committee

Results

From an initial draft of 80 competency statements 69 were adopted across 10 domains. Thirty students across the ECHO and PEACH programmes used the framework and participated in evaluation. Our analysis found that students benefited from recognising unique gerontological knowledge, expanded insights into practice and affirmation through mentor feedback. Some students faced logistical challenges including access to mentors. The framework was found to be appropriate and acceptable across both hospital, community and care home settings

Conclusion(s)

The competency framework was valid in clinical gerontological settings across hospital, community and care homes, and supported knowledge and skills development and evidencing for early career nurses.

Introduction:

Postural Hypotension is a very common presentation in the elderly population. Appropriate knowledge to record postural hypotension & non-medicinal management for this is very important among MDT members working in the care of the elderly wards.

Method:

We set out a questionnaire to assess the knowledge among MDT ( multidisciplinary) members. An educational programme was initiated to improve the knowledge among MDT members. A complete audit cycle was done and the knowledge was reassessed with the same questionnaire based on the principles of the PDSA (Plan, Do, Study & Act) cycle.

Results:

It showed that the correct way of checking for postural blood pressure improved from 52.4% to 92% in recording the blood pressure. Correct identification of postural blood pressure improved from 33.3% to 88%. Self-rating of confidence to identify correctly postural blood pressure improved from 47.6% to 64% among the MDT Members. It was difficult to compare the answers about non-medicinal methods and exercises to help postural hypotension as there was heterogeneity in answers. It was also not possible to compare the impact of individual interventions on the alleviation of postural blood pressure.

Conclusion:

Good improvement in the recording and non-medicinal management of Postural hypotension was observed in both the wards among the MDT Members. It is very important to have good knowledge and understanding in the management of this common condition as it helps in the identification and better management.