Quality Improvement

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: Our QIP was conducted in the Geriatric wards at Royal Gwent Hospital by doctors working in Geriatrics. Delirium, falls, confusion and urinary retention are common reasons for hospital admission in the elderly. Anticholinergic burden (ACB) is the cumulative effect of taking multiple medicines with anticholinergic properties contributing to frequent admissions. The aim of our QIP was to increase doctor’s awareness of ACB and encourage the review and deprescribing of regular medications in elderly patients to decrease ACB.

METHODS: ACB was measured on admission and discharge using the AEC tool by doctors and pharmacists. Baseline data was collected. Awareness of ACB among doctors was improved through education email and posters on the ward followed by another data collection. An oral presentation on ACB and stickers on patients drug charts and medical notes prompting medication review was done, followed by final data collection. A questionnaire was distributed to all doctors working in the Geriatric unit before the first cycle and after the third cycle to evaluate their knowledge on ACB.

RESULTS: Baseline data shows the percentage of patients admitted with an AEC ≥ 3 on admission and discharge was 12.7% and 10.9% respectively. In the 3rd data collection, these figures were 17.3% and 11.5% respectively. The questionnaire before and after intervention indicated that clinician confidence in identifying anticholinergic medications improved from 44% to 83.8% and awareness of tools to calculate ACB increased from 8% to 88.9%. Utilization of the AEC tool grew from 4% pre-intervention to 73.7% post-intervention. The percentage of patients with reduced AEC scores due to the interventions rose from 16.4% (baseline) to 30.7% (3rd data).

CONCLUSION: The project demonstrated significant enhancements in clinician awareness and utilization of tools to assess anticholinergic burden (AEC) in elderly patients and reduced ACB significantly, which is vital in reducing admissions in elderly.

Introduction:

Orthostatic hypotension (OH) is common in both community dwelling and hospitalised older adults. It is associated with significant morbidity, falls and all cause mortality. A spot audit of inpatients across all care of the elderly wards in Gloucester Royal Hospital and Cheltenham General Hospital revealed only 67% of appropriate patients where having documented lying and standing blood pressure measurements. Of those with documented orthostatic hypotension 44% had no documented action plan.

Methods:

Using quality improvement methodology this project aimed to achieve 100% of appropriate patients having a documented lying and standing blood pressure when admitted to a care of the elderly ward. Patients identified to have orthostatic hypotension should have this recorded in their working diagnosis with a documented action plan. Change ideas were implemented using the plan, do, study, act (PDSA) framework initially looking at recognition of OH and subsequently management of patients identified to have OH. Outcome measures included prevalence of OH in the inpatient population and inpatient falls rates. Process measures included percentage of patients with documented lying and standing blood pressure, percentage of patients with confirmed OH documented in their working diagnosis and percentage of patients with confirmed OH having a documented management strategy.

Results:

Following the first PDSA cycle the project demonstrated increased number of patients having a recorded lying and standing blood pressure, however following the second cycle a sustained increase was not seen. A third PDSA cycle is underway involving MDT education.

Conclusion:

Baseline data confirmed that in the elderly inpatient population orthostatic hypotension was both under diagnosed and under treated. Ensuring sustained change remains a challenge due to staff turnover and rotational working. Further work is ongoing to increase recognition and treatment of OH.

Introduction: A weekly ward-based teaching programme was designed and implemented using quality improvement methodology. 10 topics were identified to be covered during each 4-month rotation. 1) Topic of the week introduced via a presentation in the weekly teaching session; 2) Daily topic discussions at ward level.

Method: 7 wards. PDSA 1 (weeks 1 and 2): Weekly poster with the topic and a daily fact / question PDSA 2 (week 3 onwards): a) Software introduced to enable interaction in the teaching session b) Departmental WhatsApp used to send out daily questions. PDSA 3: a) New topics selected b) More staff groups added to WhatsApp group c) Questions weekly for each ward to ‘answer’ in the WhatsApp group

Results: Cycle 1 – little daily ward level discussion. Generating discussion in weekly teaching difficult. Cycle 2 - more engagement with both discussions. Variation in (MDT)staff group awareness. Daily teaching not habitual everywhere. Nursing staff more engaged with prompt cards than via Whatsapp. It was clear that each ward should be supported to have a different approach to delivering the teaching. Not all staff could access to weekly teaching sessions. Cycle 3 – more ward level ownership and interaction in the virtual space. The wards that have gained the most benefit from the teaching have made the questions a fixed part within their morning routine and include the entire MDT in five-minute discussion around the questions.

Conclusion: Staff working in these wards were generally positive about the weekly topic style. Having clinical leaders who are invested in teaching can support daily - cooperation and “buy-in” from those in senior roles is crucial for the development of this learning culture. This work has demonstrated some of the challenges of teaching a diverse multidisciplinary team to make information and learning accessible and useful for all.