Quality Improvement

Descriptor

NHS Forth Valley, acute services identified an 122% increase in demand for patients to receive enhanced observations during 2023-2024. The attached chart demonstrates the staff bank requests over the 12 months evidencing the 2 sharp rises during April 23 and November 23. 

Methodology

• Weekly reviews of patients placed on enhanced observation with bedside teaching
• Education programme for nurse leaders (CNM&SCN), nursing workforce and carers
• Ensuring activities are available and accessible
• Scope initiatives being used in other health boards which have proven to reduce demand of enhanced observation
• Gain feedback from patients, staff and carers on improvement ideas

Aims/Objectives

To reduce the requirement of enhanced observations by 50% by May 2025.

A sample review during a two week whole system response to acute site pressures provided intelligence that multiple patients were receiving enhanced observations but there was a lack of adherence to the current NHS Forth Valley Policy1. This highlighted patients were not appropriately risk assessed or regularly reviewed and there was also a lack of evidence that the least restrictive options had been explored. The review also demonstrated patients were not engaged in meaningful activity, cognitive rehabilitation or stimulation, which therefore provided an absence of evidence of the benefit to patient, highlighted a risk of a prolonged length of stay, risk of exacerbating stress and distress and potential increase of physical harm.  In addition, enhanced observation has a significant financial impact due to of supplementary staffing use.

The focus of the improvement work will be to ensure enhanced observations are used appropriately, is the least restrictive option, promotes recovery and benefits the patients in line with national drivers, local guidance and legislation1,2,3.

Results/Outcomes

From the project starting in March 2024 and looking at December 2024 the data confirms a 94% reduction in supplementary hours and staffing requests through the staff bank and an 86% reduction of patient identified on safecare as requiring enhanced observations, see charts attached. Qualitative measures with application of the local policy and the quality of person centred care planning has improved. These improvements combined have lead to no adverse events or complaints raised in relation to appropriate use of enhanced observations. Furthermore, the project has contributed to significant cost reduction in NHS FV nurse staffing.

References

1.NHS Forth Valley, 2022. Nursing Observations and Interventions. NHS Forth Valley. Available at: scottish.sharepoint.com/sites/FV-Guidelines/Guidelines/Forms/AllItems.aspx?id=%2Fsites%2FFV-Guidelines%2FGuidelines%2FEnhanced Nursing Observations%2Epdf&parent=%2Fsites%2FFV-Guidelines%2FGuidelines (Accessed 18 March 2025)

2.NHS Scotland, 2024. Ageing & Frailty Standards in Scotland. NHS Scotland. Available at: https://www.nhsinform.scot (Accessed 18 March 2025)

3.Scottish Government, 2000. Adults with Incapacity (Scotland) Act 2000. Available at:https://www.legislation.gov.uk/asp/2000/4/contents  (Accessed 18 March 2025)

Introduction: Urgent Care Response (UCR) provides a rapid assessment, diagnostic and treatment service to prevent hospital admission. Occasionally, patients under the UCR team require acute hospital admission. Patients were experiencing long waits in the Emergency Department (ED), despite being referred directly from the UCR team due to the ED triage system. National Institute for Health and Care Excellence (NICE) recommends ensuring coordinated and patient-centred transfer of care from one healthcare team to another. We created an electronic alert icon to notify UCR referred patients to the ED triage team. 

Method: All patients reviewed by UCR from 1st January to 29th September 2024 requiring hospital admission were included. An electronic alert notifying the triage nurse that a patient has been assessed by UCR was created on 15th July. The time taken from patient arrival to Emergency Department (ED), ED team assessment, specialist team assessment and treatment initiation was recorded before and after the electronic alert was implemented. The readmission and mortality rates were recorded for this cohort of patients. 

Results: 47 patients assessed by UCR were seen in ED prior to the implementation of the electronic alert. 26 patients were seen in ED after the electronic alert. Average patient waiting times reduced by 47 minutes for ED review, reduced by 2 hours 2 minutes for specialty review and reduced by 1 hour for treatment initiation, after electronic alert implementation. 26/47 and 20/47 patients were readmitted and died respectively prior to electronic alert. 9/26 and 3/26 patients were readmitted and died respectively post electronic alert. 

Conclusion: The introduction of the electronic alert significantly improved time to ED team review, specialist team review and treatment initiation. Readmission and patient mortality within 12 months were recorded for the patient cohort. Post electronic alert, patient readmission reduced by 21% and patient mortality reduced by 31%.

Introduction: Hip fractures, predominantly affecting older adults, represent a significant health concern due to high morbidity, mortality, and healthcare resource utilisation. This ongoing Quality Improvement Project within Forth Valley Royal Hospital aims to enhance adherence to recommendations from the 2023 and 2024 Scottish Hip Fracture Audit. It specifically focusses on the timely administration of Vitamin D and IV Zoledronic Acid to frail patients with hip fractures.

Method: A retrospective and prospective cohort study design was employed, analysing the records of 165 inpatients under orthogeriatric care from November 2023 to May 2024. Initial data analysis indicated low rates of IV zoledronic acid and vitamin D administration, primarily due to clinician unfamiliarity and process inefficiencies. Subsequent interventions included staff education sessions, process standardisation, and the introduction of tracking tools such as Bone Health stickers and whiteboards. Formal referral pathways and decision-making protocols were implemented to ensure comprehensive and timely patient care.

Results: The interventions led to substantial improvements in adherence rates. Between November 2023 and March 2024 vitamin D administration rates increased from 14.71% to 100%, and IV Zoledronic Acid administration rose from 12.12% to 95.45%. These improvements were achieved through systematic tracking, enhanced clinician education, and standardised care processes. Despite these gains, challenges remain in achieving 100% adherence to IV Zoledronic Acid administration and addressing initial data capture inaccuracies due to inconsistent use of referral systems.

Conclusion: The project demonstrates that targeted interventions and standardized care pathways substantially improve adherence to national guidelines for hip fracture patients. Sustained efforts in education, process refinement, and collaboration with the Hip Fracture Audit Team are essential to maintain these improvements. Future proposals include integrating Vitamin D and Adcal-D3 doses into an electronic prescribing protocol and conducting detailed statistical analyses to identify further areas for improvement.  

Introduction:

Falls in older people are associated with multifactorial risks which are often preventable. Last year there were over 220,000 emergency admissions for falls in people aged 65 years and over in the UK. Improving how we assess such patients on admission may help to ameliorate these risks and prevent future admissions.

Method:

The aim of this quality improvement project was to identify weaknesses in our acute risk assessment of multifactorial falls and to improve on these. We completed a retrospective case note review for 68 patients in their first 48 hours of admission. As an analytical framework, we adopted the NICE guideline: ‘Falls in older people: assessing risk and prevention’ which details twelve key parameters of risk assessment. For each patient we sought to determine whether these parameters were assessed or missed. After the first audit cycle, we found four guideline parameters which were commonly missed during the acute admission phase. An educational intervention was subsequently organised for medical staff at a departmental level and corroborating posters were placed around the acute areas of the hospital. Two months later a second audit cycle was undertaken which assessed the same parameters and looked for improvement.

Results:

There were notable improvements in four areas. The assessment of visual impairment increased from 32.4% to 42%. The documentation of patients’ perceived risk of falling improved from 37.3% to 60.9%. Osteoporosis risk assessment rose from 32.4% to 63.8%. The completion of Lying/Standing BP demonstrated the most significant increase, from 14.7% to 44.9%.

Conclusions:

The results suggest that a tailored educational session and a poster campaign have increased overall awareness and improved the risk assessment of multifactorial falls at a central Birmingham Hospital.

Introduction: Discharging patients from hospital is a complex process which requires multiple professions and processes. Late afternoon discharges can lead to admission bottlenecks and contribute to emergency department overcrowding. Focusing on discharging patients earlier in the day, can contribute to greater flow through the hospital and greater patient satisfaction. Leeds Teaching Hospital Trust (LTHT) aims to achieve 70% of discharges before 3pm. The Specialist and Integrated Medicine (SIM) department care for frail elderly patients who are at increased risk of harm following prolonged stays in the emergency department and were discharging 30% of patients before 3pm.

Method: To gain greater understanding, a survey was conducted amongst various staff members to understand their perceptions of why delays occur in patient discharge. A deep dive into discharges after 3pm was also conducted to identify avoidable delays. This enabled multicomponent interventions to be developed with the team and enacted across SIM. These included:

- Education about the importance of timely discharge

- Community discharges prioritised in pharmacy the day before

- 'Golden patient' identified on wards for morning discharge.

- Promoting utilisation of the discharge lounge

- Recognition of achievement for wards

- Recruiting of junior doctors to lead individualised ward QI projects to improve earlier discharge

- Involvement of senior leaders to have buy in from consultants and senior managers

- Discharge boards being utilised.

Results: SIM achieved a 12% improvement in number of discharges before 3pm which has been sustained despite increasing pressures on the department. This is the highest median ever achieved by the department.

Conclusion: Achieving patient discharges earlier in the day is complex and requires a multifocal approach from multidisciplinary professionals. The interventions used were based on an in depth look at data and developing an understanding of the perceived and actual barriers from the team themselves.