CQ - Patient Centredness

Aim

Emergency laparotomy is associated with a high mortality and morbidity. Early identification of high-risk patients allows for timely involvement of other members of the multidisciplinary team, including care of the elderly (CoE) specialists. This improves the likelihood of a successful post-operative recovery. This study investigated the adherence to the NELA guidelines regarding the use of the clinical frailty score and input from the CoE team.

Methods

A prospective analysis was conducted, collating data on patients undergoing an emergency laparotomy in one centre in East London. Data collected included the date of admission, findings at operation, clinical frailty scores, and input from CoE team members.

Results

16 patients had an emergency laparotomy during May 2024. Ages ranged from 44 to 92. 11 patients were aged 65 years or older but none had a clinical frailty score within 4 hours of admission, as per NELA guidelines. 6/11 (55%) were reviewed post-operatively by the CoE team during their inpatient stay. These findings were reported at the monthly morbidity and mortality meeting. Our interventions included a surgical teaching session, posters in the department and a stamp for CoE review kept in CEPOD theatre for use post-laparotomy. The second cycle showed significant improvement with a 33% increase in CFS and a 12% improvement in care of the elderly reviews.

Conclusions

In conclusion, it is known that older patients have a poorer post-operative outcome, which is improved by perioperative CoE input. With this audit, we improved awareness within our department regarding older, frail patients and began to see a change regarding assessing patients mobility and need for CoE input. However, we are still not doing this for all of our patients so there are still improvements to be made. Interestingly, in terms of interventions, we found that teaching and discussion had the greatest impact.

There is a 35-week waiting time to be seen in a gastroenterology clinic for investigations such as UGI endoscopy and colonoscopy for a condition such as low Hb, weight loss, dysphagia and so on. Most of the time without adequate initial workup and ruling out iron-deficient anaemia and differentials as per the British Gastroenterology Society. The hospital is witnessing an exponential influx of patients, reflecting in long waiting times to accommodate clinic patients.

The current established low Hb referral pathway via GP to gastroenterologists does not consider the co-morbidities and frailty. Hence the main aim of the pilot project is to create parameters and filter patients who are 75 and above with co-morbidities and 85 and above, who would benefit from a comprehensive review, whose outcome might involve invasive gastroenterology investigation. The patients will be able to address their GI problems and other concerns where a Geriatrician will provide the expertise in a personalised care plan.  The Gastroenterology triaging secretaries will filter the suitable patients based on established parameters following referred to an Elderly Care consultant in comprehensive assessment clinics. In the clinic, the patient will have a thorough workup for causes of low Hb or GI causes, assess the level of frailty, and discuss with the patient if they want to go for invasive investigations or manage their condition conservatively. The project will provide holistic, patient-centred care and prevent delays in care plans.

Furthermore, help conserve endoscopy resources where the patient chooses not to have further invasive procedures—resulting in overall patient satisfaction.

Introduction: Femoral fragility fractures (FFFs) are a significant healthcare concern, with the incidence predicted to rise to 100,000 annually in the UK by 2033. Current secondary preventative strategies focus on the patient’s physical state – overlooking Hospital-associated Deconditioning (HAD), the decline in patient wellbeing post-admission. To prevent HAD, a ‘Games Area’ (GA) was introduced in December 2023 as a service improvement. This study evaluates the GA’s effectiveness in preventing HAD, by assessing patient satisfaction.

Method: We evaluated all patients aged 65yrs or more during their post-operative rehabilitation for their FFF who were deemed fully weight-bearing and medically ready for discharge. The control group received the standard care provided by the ward’s multidisciplinary team, while the GA group also had access to the GA, where patients were encouraged to participate in activities with fellow inpatients. Activities included colouring, jigsaw puzzles and wordsearches. Data were collected via weekly questionnaires and medical records.

Results: Overall, 75 patients participated (38 in the control group, and 37 in the GA group). Patients in the GA group reported higher satisfaction ratings, with a mean score of 3.01 (SD = 0.406) out of 5, while the control group’s mean was 1.83 (SD = 0.279).

Conclusion: The GA acts as a simple, cost-effective intervention that can mitigate HAD by enriching the ward environment – hence, enhancing patient experience, and may improve patients’ physical, mental, and emotional health.

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.

Introduction: The number of adults in the UK who identify as transgender is increasing, through greater recognition of trans identity and growing numbers of individuals transitioning in later life. The term “Transgender” encompasses a diverse range of experiences and identities, including those who identify as non-binary, gender-fluid, and gender-queer. However, within this review, we use the shortened term “trans” and the following broad definition: “people whose gender is different from the gender assigned to them at birth.” We conducted this exploratory review to examine the literature regarding the specific health and social care needs of older trans adults.

Methods: We utilised scoping review methodology and thematic qualitative analysis to systematically search and map the literature related to the physical and mental health challenges related to the ageing experience among trans adults in the UK.

Results: We identified 22 relevant papers through combined systematic search and additional manual reference review. We recognised five key themes within the literature: Systems and Structural Factors, Health and Mental Health, Social Care, Diversity and The Future. The former three themes relate to limitations presented by current models of care, barriers within services and potential areas for development. Key areas identified include challenges related to the application of a binary gender model within healthcare systems as well as advanced care planning and ensuring gender-affirming care where capacity is lost including living with dementia. The latter two themes identify gaps in the current literature and provide examples of trans-inclusive positive practice.

Conclusions: There is an ongoing need for researchers, clinicians and policymakers to ensure that the needs of older trans adults are studied, understood and accommodated within policy and practice. Service providers delivering care to older adults must understand trans-specific needs, particularly around advanced care planning, to ensure that trans people are supported to age well.

Background: NICE guidance for administration of dopaminergic medications is within thirty minutes of the prescribed time. Patients with Parkinson's Disease are frequent attenders of the ED, often leading to admission for a variety of reasons. Medication timing as an inpatient is frequently sub optimal, leading to potential harm of the patient and prolonged inpatient stays. Interventions previously seen to be beneficial include medication posters and alarms, tested across multiple wards at a different trust. This project aims to assess three interventions looking to improve the administration time of dopaminergic medication at Aintree University Hospital. Method: Three interventions were assessed: education, medication timesheets ad medication timers. These were assessed on one surgical and one medical ward. Baseline data was collected prior to implementation, then following each data was recollected. Nursing staff opinion and knowledge were also assessed using surveys at baseline, following education and at the end of the project. Results: Baseline data showed an average of 18.75% of doses given out of range on the surgical unit. Education proved to be useful, reducing the average to 12.5%. Medication timers were the most promising intervention, improving the average to 10.7%. However, when plotted on a control chart the changes appear unconvincing for significance. Surveys showed an initial reluctance for the use of timers, but following their use they then became the preferred intervention. Obstacles to their use were identified, such as loss of instructions and difficulty in changing the settings. Conclusion: This project has found evidence to support the use of medication timers to facilitate more accurate administration of dopaminergic medications. However further assessment is required with a follow up QI project given the uncertainty seen on the control charts.

Introduction: A BMJ study suggested that 1 in 5 sick, older patients have a ‘do not resuscitate’ document and a large proportion only had this completed in the Emergency Department (ED) (1). Current ED pressures could cause greater delay in this discussion, resulting in inappropriate cardiopulmonary resuscitation (CPR). The ReSPECT form was established to bring consistency to the communication of patients wishes, including ‘do not attempt CPR’ (DNACPR) (2). This QUIP assessed the incidence of inappropriate CPR in two ED’s by investigating the proportion of CPR performed on those with a prior DNACPR or ReSPECT form.

Method:

Data was collected retrospectively from cardiac arrests in two ED’s between the 1st of January 2023 and the 17th of November 2023. The three parameters assessed were the number patients undergoing CPR, number with prior DNACPR/ReSPECT forms, and how often CPR occurred within 30 minutes of patient arrival. Hospital A used ReSPECT forms, whereas Hospital B did not.

Results:

Over the assessed period, CPR was performed on 21 patients at Hospital A. Of these, 19% had prior DNACPR/ReSPECT forms and 43% of CPR was within 30 minutes of patient arrival. 10 patients received CPR at Hospital B. Of these, 0 patients had prior DNACPR/ReSPECT forms and 40% of CPR occurred within 30 minutes of patient arrival.

Conclusion:

Hospital A performed CPR on more patients with prior DNACPRs compared to hospital B. Occasionally, these DNACPRs were on the GP portal but were not easily accessible in the hospital setting due to the hospital’s paper-based notes system. Both sites performed CPR on a similar proportion of patients within 30 minutes of admission. This highlights the importance of prompt decisions, communication and the need for community discussion with documentation that is easily accessible across healthcare 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.

Introduction: Delirium affects up to 50% of older individuals within hospital environments, with a notable occurrence in 30% of those aged 65 and above in emergency departments. This QIP aimed to enhance the early recognition of delirium by implementing the 4AT assessment and optimize assessments and investigations by implementing the Delirium Bundle.

Methodology: A survey involving 39 doctors was conducted to evaluate their comprehension of delirium and awareness of the Delirium Bundle. PDSA 1 involved retrospective data analysis of medical records for patients admitted with delirium and used as a preliminary baseline to evaluate how the delirium bundle is being utilized. PDSA 2 integrated multiple teaching sessions and the implementation of the Delirium Bundle, assessing the effectiveness of these interventions.

Results: In PDSA 1, twenty-nine patients were identified. None of the patients had a 4AT assessment done. Twenty patients (69%) had a hematological screen done, eight patients (27%) had an ECG done, twenty patients (69%) had a CXR done, eighteen patients (62%) had an MSU test done, eight patients (28%) had cultures done, and twenty-three (79%) had a CT head scan done. In PDSA 2, thirty patients were identified. Seven patients had a 4AT assessment done, sixteen patients (53%) had a hematological screen done, nineteen patients (63%) had an ECG done, twenty-two patients (73%) had a CXR done, fifteen patients (50%) had an MSU test done, fourteen patients (47%) had cultures done, and 20 patients (67%) had a CT head scan done.

Conclusion: The implemented changes showed effectiveness with increased 4AT assessments and enhanced confusion screening. Improvements in assessments and investigations for diagnosed delirium patients were evident. To further enhance efforts, future initiatives include incorporating the 4AT assessment in clerking booklets, conducting continuous teaching sessions, and displaying posters in relevant wards.

Wipes are a practical solution for cleansing skin and widely used in children, neonates, and in geriatric care. Some wipes contain compounds may cause dryness, itching, irritation, and inflammation. This abstract looks at the efficacy of wipes that do not contain multiple unnecessary added ingredients.