Training and Careers

Introduction

Frailty is a condition with increasing prevalence in the UK and significantly impacts the lives of those affected and their families. Frailty is a condition best managed by teams of skilled multi-disciplinary health and social care professionals (HSCPs). It is therefore essential that all HSCPs working with older people living with frailty are equipped with the appropriate knowledge and attitudes to look after affected persons.

Methods

The British Geriatric Society (BGS) and NHS England (NHSE) collaborated to produce an online e-learning module to support HSCPs to provide frailty care in complex situations and lead frailty services. This module was developed in line with the NHS Skills for Health Frailty framework of core capabilities at the tier 3 level. The e-learning module was launched in October 2023 and contained 4 modules: Understanding and Communicating Frailty, Identifying Frailty, Supporting People Living with Frailty and Building Systems Fit for Frailty. This module was made available for free to BGS members.

Results

Between October 2023 and January 2023, over 4000 HSCPs registered for the online module. A wide ranges of HSCPs signed up for the module with nursing staff, advanced clinical practitioners, consultant geriatricians and physiotherapists the most commonly represented groups. 92% of those who completed the module agreed or strongly agreed that the course helped develop knowledge, understanding and confidence in frailty. 91% of those who completed the module said completion of the course would help them to further improve patient care and clinical practice. Areas identified to enhance the module further included addition of further case studies and making the resource more adaptable to all UK regions.

Conclusions

e-Learning can be an effective facilitator of frailty education for a wide range of HSCPs.

Introduction

The British Geriatrics Society “Joining the Dots” blueprint recommends delivery of inter-professional education aligned with the Skills for Health Frailty Core Capabilities Framework as part of a system wide frailty strategy. Our ambition is to educate and train the entire health and care system in frailty awareness through the Guildford & Waverley Frailty Academy (GWFA).

Methods

The GWFA developed a Frailty Awareness course aligned to Tier 1 Core Capabilities and introduced this as part of a system wide programme of education and workforce development in frailty. The course was embedded in e-learning platforms across Acute, Community, Ambulance services and Local Authorities. A blend of virtual and face to face (FTF) workshops were used in undergraduate University programmes, the Voluntary sector and care sector.

Results

Between April 2023 and July 2024, 2,195 people completed Tier 1 training.

• Care sector, voluntary sector, Fire service, trading standards: 147 through 7 virtual workshops

• Undergraduate students at the University of Surrey: 234 (FTF)

• Acute, community, Local Authority, Ambulance service: 1,814 people through e-learning

Feedback showed the following:

• 83% said they had good/significant improvement in knowledge after participating in virtual workshops.

• 79% of paramedic students rated their improvement in knowledge and skills as good/ significant as a result of attending their session.

• 90% of nursing students rated their improvement in knowledge and skills as good/ significant as a result of attending their session.

Qualitative responses showed participants felt more aware of frailty and had a better understanding of how to adapt their practice when encountering older people with frailty.

Conclusions

Tier 1 training is an effective method of raising awareness of frailty across a health and care system when applied as part of a broader system strategy using a variety of mediums for delivery.

Introduction

Incidents and complains are an important form of learning for healthcare institutions. The learning is often shared via huddles, handovers, emails and learning alert bulletins. In the older persons medicine (OPM) department at James Cook University Hospital, we identified that there may be a role for whole team in-situ sim to not only facilitate learning around important and highly relevant topics but also improve the education provision for nurses and healthcare assistants who have less access to education compared to their doctor colleagues and improve whole team communication.

Methods

Initially a working group including a consultant, advanced clinical practitioner, SIM training facilitator, liaison psychiatry nurse, teaching fellow and ward manager was set up to organise a pilot session. Following the success of this session the training was initially organised to be monthly, arranged by the advanced clinical practitioners, facilitated by the sim technicians. The ward managers fully supported the training and facilitated the attendance of the ward staff. The clinical director identified topics for learning from incidents and complaints and there was support from the OPM registrars and teaching fellow. It quickly became so popular amongst staff that the session frequency was increased first to fortnightly and is now run weekly.

Results

The feedback was excellent. From the attendees, to the sim trainers who said that the OPM department had been the most enthusiastic about ward-based training. The anonymised and entirely positive feedback from the sessions was that they were interesting, informative, and relevant to clinical practice.

Conclusion

Using in-situ simulation training on the older persons medicine wards to share learning from incidents and complaints is not only practical, but incredibly well received by staff of all disciplines.

Abstract Content - Introduction

We wished to improve the knowledge of care home staff in Leeds in identifying frailty and managing frailty related problems

Method

We developed a frailty education course (www.leedsfrailtyeducation.co.uk) which was then refined and modified to target care home staff. We engaged key stakeholders at the council and the ICB to help develop and promote the course. The course was delivered across 4 venues in Leeds by geriatricians, a pharmacist and a community nurse.

Results

We had 128 attendees across the four days. From the feedback taken immediately after the study day (n=69): -100% of attendees found that the content was useful and well delivered. -97% of attendees improved their knowledge of frailty and 100% improved knowledge of CGA. -CGA, assessing delirium and positive approaches to managing dementia were the 3 most common things attendees intended to take away for their future practice. From the follow-up feedback (n=19): - 95% (18/19) ‘extremely agree’ with the statements “Attending the training day has improved my understanding of frailty” and “I would recommend my colleagues attend this course” -42% (8/19) have implemented frailty assessments as part of standard care in some form Attendees also valued the multi-sector, multi-professional expert presenters alongside the opportunity to meet and interact in-person.

Conclusion(s)

A dedicated study day for care home staff was well received by attendees and feedback received demonstrated self-reported lasting change to practice. Key enablers to the success of the course were: the reputation of the course locally which had been piloted and delivered in different formats previously, tailoring the material to the audience, and delivering the course in several different locations. More regular frailty teaching days can be implemented to capture more care home staff and ultimately improve care for residents.

In hospital incontinence increases length of stay (1), in orthopaedic patients is associated with increased likelihood of discharge to an institutionalised setting (2) and can have a major negative impact, with many rating bowel and bladder incontinence as a health state the same or worse than death (3). Yet of the Geriatric Giants, it is given relatively little attention.

At a busy teaching hospital, we sought to raise awareness and improve management of incontinence across our 167 beds, by using a standardised, multi-disciplinary approach involving identification of patients and use of the components of BASICS (Bladder diary, A physical assessment, Symptom profile, Infection and Constipation check and a bladder Scan, figure 1).

Baseline data of a sample of 14 patients with new urinary incontinence with their aspects of continence assessment were added to a cumulative audit. Alongside checklists, a poster(figure 2) was designed and placed on each ward, a local teaching session about incontinence was delivered, and data shared at our local governance meetings. Following this, a further cycle of audit was performed. Reversible causes were identified and addressed appropriately. Between cycle 1 and 2 (February and June 2024), significant improvements were seen in most aspects of BASICS assessment with notable increases in use of the bladder diary (7 to 50%) and medical examination (7 to 57%). See figure 3 for breakdown.

As a consequence, there were multiple interventions aiming to improve patient symptoms. Paying consistent and sustained attention to this neglected area of practice has demonstrated a change of culture is possible. We are now incorporating continence assessment into our medical trainee audit programme to support a sustained multi- disciplinary approach and maintain improvements.

Introduction 

Geriatric medicine is inherently complex and requires multidisciplinary integration. Simulation-based training is recognised as a method to enhance learning and improve patient outcomes.  

This project aimed to develop a multi-professional simulation programme within care of the elderly to mimic the multi-professional practice of geriatrics. 

Methods  

Ten half-day simulation sessions were run across two sites over two years. The scenarios cover frailty, orthogeriatrics, acute delirium, Parkinson’s disease, thrombolysis and palliative care.  

There were 57 participants, including 24 doctors, 20 nurses, 7 nursing students, 4 healthcare assistants and 2 physician associates.  

Quantitative and qualitative questionnaires conducted pre- and post- simulation were used to assess confidence levels and attitudes towards simulation.  

Results 

Both pre- and post- simulation, candidates had the most confidence in managing end-of-life situations, and least confidence in managing patients with Parkinson’s disease.  

Confidence levels for managing common geriatric scenarios increased by an average of 21% after candidates participated in the session.  

Thematic analysis highlighted the importance of collaboration within a team and pro-activeness of staff to highlight deteriorating patients to colleagues and family members.  

Conclusions 

Simulation that mimics the ward environment is an effective tool in increasing the confidence of the MDT looking after geriatric patients through exposing candidates to complex situations and increasing awareness of roles within the team.  

The simulation sessions have highlighted common clinical areas that require further education within the Trust, such as thrombolysis. Future development of the simulation will aim to adapt the scenarios for the use of the wider MDT.

Introduction

Board round is essential in geriatric care for clinical prioritisation, planning discharges and identifying any barriers to discharge. This process can be limited by poor handover, lack of roles and a defined structure. This project aimed to improve board round efficiency in an inpatient acute frailty setting.

Methods

The project involved a 2 stage PDSA cycle including data collection at baseline and after each successive intervention.

Stage 1: Role allocation and Board round proforma

Stage 2: Doctor education

Data related to several outcomes was collected retrospectively over 4-5 days per cycle. Inclusion criteria included all inpatients on the acute frailty unit at the time of each daily morning board round. Qualitative data was collected at baseline and after cycle 1.

Results

Improvement was shown in all outcomes after two cycles:

• Board round length (<30 minutes)
• Principal problem listed correctly (33% to 76%)
• Medically fit patients marked correctly (57% to 83%)
• Time since problem list last reviewed (11 days to 1.9 days)
• Proforma completed (89%)
• Proforma visible in the patient notes (68%)

Conclusion

This project demonstrated improvement in terms of accuracy and efficiency to the board round process. This has implications for geriatric patient care and flow.

The format has been rolled out to other medical wards across the trust helping to standardise the board round process.

A further intervention of a ‘Smartphrase’ and teaching sessions to facilitate updating the problem list has been implemented with further data collection planned.

Introduction

National guidance suggests that all patients with neck of femur fractures (NOFF) should be mobilised day one post-operatively (NICE, 2023, QS16). This reduces rates of delirium, pneumonia and length of stay (Sallehuddin & Ong, Age and Ageing, 2021, 50, 356-357). Hypotension is a leading cause of immobilisation post-operatively. National guidance advises appropriate fluid resuscitation and review of polypharmacy when indicated (British Orthopaedic Association, 2007). This quality improvement project aimed to reduce post-operative hypotension and improve day one post-operative mobilisation in NOFF patients.

Method

Three months of NOFF patients were retrospectively reviewed pre-intervention. Those who did not receive surgical intervention were excluded. The proportion of NOFF patients that were unable to mobilise due to post-operative hypotension on day one was identified. We reviewed if intravenous fluids were given pre-operatively and if anti-hypertensives were held. An intervention was then implemented including educational posters and teaching sessions for doctors and nurses to encourage prescription of fluids on admission, holding of antihypertensives pre-operatively and detection and escalation of oliguria or hypotension post-operatively. Data were then re-collected in a three-month period post-intervention to ascertain if there was any change in practice.

Results

70 patients underwent NOFF repair pre-intervention compared to 54 patients post-intervention. There was a decrease in the proportion of patients unable to mobilise day one post-operatively due to hypotension from 15.7% pre-intervention to 9.3% post-intervention. There was an increase in the proportion of patients who received pre-operative intravenous fluids from 64.3% pre-intervention to 77.8% post-intervention. Of those patients who took anti-hypertensive medication, a higher proportion had this suspended pre-operatively, increasing from 82.9% pre-intervention to 88.2% post-intervention.

Conclusion

Simple educational interventions can reduce post-operative hypotension in NOFF patients. Developing local guidelines may facilitate persistent clinical change, as improvements following poster distribution and teaching sessions may be transient.

Introduction: Orthostatic Hypotension is a significant cause of falls leading to injury and morbidity in elderly population. In an online survey by Royal College of Physicians (RCP) 271 out of 316 clinicians routinely performed these measurements and there were significant variations in how lying and standing BP is performed. This could have adverse effects on detection rates and accuracy of the procedure resulting in misdiagnosis. As a result, RCP has released guidance on L/S BP2 measurements in view of standardising practice and improving accuracy. The purpose of this QIP is to improve how L/S BP is measured and documented, by introducing poster on wards and re-audit the improvement in the correct method of measuring L/S BP.

Methods: Ward staff are audited to find out whether LS BP is measured as per RCP guidelines. Afterwards a poster of RCP recommended method of measuring LS BP are placed on ward and given to participants. The procedure of L/S BP measurement is re-audited after the intervention to find out changes in performing L/S BP (as per RCP guidelines).

Results: • 20% staff were aware of RCP guidelines on L/S BP procedure (90% after intervention). • 0-15% staff had formal training on how to measure L/S BP. • Over three times improvement in the method of procedure (20% to 65% after intervention). • 25% staff were documenting symptoms (improved to 85% after intervention). • 10% of staff knew how to interpret a positive result, improved to 60% after intervention.

Conclusion: • Staff education improves L/S BP Procedure, documentation and interpretation, it also helped raise staff awareness of the RCP guidelines and how to access them.

Introduction

At Epsom and St Helier, a dedicated Frailty service exists during daytime hours, and not weekends, nights or Bank Holidays. During these hours, patients are reviewed primarily by a cohort of “frailty-naïve” medical junior doctors. We aimed to compare the management plans, patient outcomes, rates of discharge, documentation and care delivered by medical junior doctors to that of an established frailty service.

Methodology

Data on presenting complaint, demographics, degree of frailty, postcode was collected on all patients over the age of 65, presenting to A&E at Epsom and St Helier Hospitals with a Frailty Syndrome. Patients who presented with symptoms or signs outside of the frailty syndrome criteria were excluded. The Medical Service was compared to the Frailty Service on rates of discharged and whether or not a resuscitation status, an escalation plan, baseline functional assessment, vision and hearing assessment, home set-up assessment, cognitive status, the elicitation of patient preferences and a medication assessment were performed.

Results

In 202 patients, average age was 85.2 years and consisted of 85 men and 117 women. Unwitnessed falls were responsible for 143 presentations. 127 patients were Caucasian and from the least deprived deciles. 109 patients (54%%) were seen directly by Frailty, and another 93 (46%) seen as referrals to the Medical Doctors. 33(16%) of patients were discharged by Frailty within 24 hours of admission, compared to 15(7.4%) by the Medical Team. The Frailty Service was more proficient in assessing patient baseline status (OR1.71), property (OR1.64), cognition (OR1.43), medications (OR1.28) and patient preferences (OR21.95).

Conclusion

Frailty reviews at an early stage in patient presentation to hospital was twice as likely to result in discharge within 24 hours of admission. Additionally, patients were more likely to have a thorough, comprehensive frailty assessment, and were significantly more likely to be empowered in their decision-making process.