CQ - Patient Centredness

Introduction:

Care home residents are increasingly presenting to hospitals. In October 2022, a frailty team was formed in our district general hospital, consisting of two SHOs, one SpR and one consultant, with support from pre-existing care home ANP and community resource team (CRT). Focusing on patients presenting to the Emergency Department, their aims were early identification of care home residents in order to optimise their care by facilitating discharge, tackling polypharmacy and seizing opportunities for advanced care planning.

Method:

Care home residents were highlighted on the ED clinical system, using a unique icon, and reviewed by the frailty team. Anonymised patient statistics were logged into a bespoke e-database. This generated a dashboard of graphs showing trends in outcomes. The statistics from the first 8 months (3/10/22 to 5/6/23) were utilised to show patient demographics, number of reviews and rates of discharge.

Results:

297 care home residents were reviewed. 83.8% of these patients had a Rockwood Clinical Frailty Score of ≥ 7. Delirium was present in 91 (30.6%) patients. 121 (40.7%) had at least 1 medication stopped. 165 (55.6%) were discharged after frailty review. Do not resuscitate forms were completed for 208 (70.0%) patients. Advanced Care Planning was discussed with 138 (46.5%) patients and 6 (2.0%) patients were not for re-admission. End of life care was commenced for 17 (5.7%) patients.

Conclusion:

It is clear that patients attending the Emergency Department would benefit from an early comprehensive geriatric assessment. The benefits this has provided in one North Wales DGH are significant and have made strides in reducing unnecessary admissions, reducing polypharmacy and providing holistic, interdisciplinary and patient centred care including advanced care planning. Whilst the Emergency Department is not an ideal environment for this, the team have demonstrated the benefits to this model.

Introduction: Patients with learning disabilities (LD) often have complex medical needs resulting in onset of frailty at younger ages. This increases risk of morbidity and mortality following emergency admissions, such as acute fractured neck of femur (FNOF). This risk is further increased by communication difficulties experienced in this group. There is little information about how LD affects the quality of care of patients with FNOF as defined by the national hip fracture standards (NHFS).

Methods: This retrospective audit reviewed notes of patients with LD admitted to a teaching hospital with FNOF over 5 years. The audit examined whether the care of patients with LD complied with the NHFS and best practice tariff guidelines, regardless of age. The audit sought to explore potential disparities between patients with LD and the general population. It assessed whether steps were taken to optimise care as defined by the Royal College of Physicians toolkit for LD.

Results: 46 patients were included; 22% were under the age of 60. Operative management was in line with recommendations. However 37% did not receive appropriate bone strengthening treatment and 37% were not mobilised within the first 24 hours. This correlated with fewer patients remaining freely mobile following the admission (8.7% post-operatively vs 41.3% pre-operatively). Documentation of LD severity LD and usual behaviours was unreliable, as was documentation of key conversations, such as those regarding capacity or resuscitation.

Conclusions: This highlights the importance of addressing the increased needs of patients with LD regardless of age, to better facilitate holistic assessment and treatment of this vulnerable population. Locally we plan to minimise variation by utilizing LD nurses and providing comprehensive geriatric review of all patients with LD admitted with FNOF. We recommend that data collection, including 120-day follow-up, be incorporated into routine practice for all patients with LD admitted with FNOF.

Introduction

Receptive music listening has been shown to reduce depression, anxiety, and agitation in older adults. However, unfiltered and disruptive noise can increase confusion and agitation. Yet, during hospitalization older patients often have little control over when and for how long they are exposed to music, the genre which is heard, or they may have no access to music. Furthermore, older persons have reduced ability to use modern technology to counter this and their sensory and functional impairments may further isolate them. This study aimed to assess the feasibility of offering two one-hour daily sessions of patient specific music (PSM) choices on an elderly-care ward.

Methods

On an district general hospital elderly-care ward a 5-day trial of offering two one-hour daily sessions of PSM, using enhanced wireless speakers optimally positioned with daily amended music playlists based on specific patient choice. Ambient noise was minimised with regular decibel monitoring. A post-intervention staff survey was completed to assess the feasibility of continuing, the perceived impact on staff and patients and potential barriers to continuation. Thematic analyses were completed on the survey.

Results

In the post-intervention feasibility survey (n=14) the majority of staff (86%) agreed that it was possible, implementable and the procedure easy to use. In the impact assessment (n=19) 80% of staff stated it had a positive effect on patients and 89% stated it had a positive effect on staff. Thematic analyses on impact identified benefits to: work, engagement, enjoyment, physical activity and well-being. Barriers that were identified included patient choice, repetition of music, patients unable to engage with the process and staff availability for consistent delivery.

Conclusion

Playing patient specific music choice was feasible and acceptable to staff with a perceived positive influence on both staff and patients. Further studies are now required to assess the impact on patient outcomes.

Introduction: Treatment Escalation Plans (TEPs) are helpful tools that reduce un-necessary treatment burden, improve patient experience and follow the principles of realistic medicine. This is relevant in orthopaedics where a high percentage of the patients are frail, co-morbid, and would benefit from clear and realistic care plans. We aim to improve TEP completion to >50% of orthopaedic patients, over the age of 65yrs old, in three trauma wards at the Royal Infirmary of Edinburgh by August 2023.

Methods: We sampled three patient notes on each ward twice weekly from May – August 2023, noting whether TEPs were present, if it was consultant endorsed or provisional, and what key sections were completed (resuscitation, treatment goals and communication). To be included, the patient had to ≥65 and under orthopaedics. Process mapping demonstrated 2 key targets- admission clerk-in and registrar review. PDSA 1 involved creating a prompt for documenting TEPs on FY1 clerk-in which was added to the admission proforma folder and displayed as posters. PDSA 2 was a teaching session designed for orthopaedic registrars and other team members about TEP conversations.

Results: Pre-intervention data, demonstrated a median of 28% of orthopaedic patients ≥65yo have a TEP. Of the completed TEPs: 88% solely consisted of a resuscitation decision; 33% had treatment goals, 33% communication; and 0% of TEPs were endorsed. After PDSA 2; median TEP completion increased to 33%. Of the completed TEPs; none had only a resus decision, 100% have treatment goals; 100% communication, and 83% are endorsed.

Conclusions: Our studies have demonstrated that education and proforma changes have increased TEP documentation rate, although not to our projected target. However importantly, the percentage of TEPs that contain goals, document communication and consultant endorsement has improved significantly. This project is ongoing with with planned further PDSA cycles.

Introduction:

Atrial Fibrillation (AF) causes 15% of ischaemic strokes. The National Clinical Guideline for Stroke recommends at least 24 hours of cardiac monitoring and a longer duration if cardio-embolic stroke is suspected. The British Heart Rhythm Society suggests up to 72 hours of cardiac monitoring. Currently, there is little data on the use of telemetry in detecting AF in acute strokes.

Aims:

Our study aims to evaluate the detection rate of new onset AF in acute stroke with telemetry and to determine if there was any correlation between the duration of telemetry and the detection rate of AF.

Methods:

All patients with ischaemic stroke who were admitted to stroke ward over a 3-month period were retrospectively analysed. Exclusion criteria were patients who were known to have AF, had new AF on admission electrocardiogram, patients receiving palliative care, patients who were discharged home early without having a telemetry and patients with missing records.

Results:

61 patients met the inclusion criteria and 5 (8.2%) had AF on telemetry. Two patients had AF on day 1, one on day 2 and two on day 3. All of these patients were anticoagulated. The duration of telemetry ranged between 1- 19 days however no AF was detected beyond the third day of this study.

Conclusions:

AF was detected in 8% of patients with ischaemic stroke within the first 72 hours of admission. Among the patients in whom AF was detected, 5% were detected between 24 hours and 72 hours of admission. Studies (EMBRACE and CRYSTAL trials) have shown that prolonged cardiac monitoring (30 days and 6 months to a year respectively) resulted in higher detection rates of AF. This study suggests that patients with ischaemic stroke should be monitored for at least 72 hours due to a higher detection rate of AF.

Background End-of-life (EOL) care aims to anticipate, prevent and treat symptoms experienced by the dying patient. An EOL care strategy described by King’s Health Partners (KHP) outlines the ‘ICARE’ framework, created from the five priorities for the dying patient, giving generalist hospital teams a memorable prompt to consider holistic needs of patients. We aim to reconcile performance of Acute Medical Unit (AMU) in providing EOL care, against KHP's framework, to reduce patient suffering and improve care. Methods A prospective review was performed of all AMU deaths from March-September 2021, reviewing resuscitation status and EOL medications. Sudden deaths for full resuscitation were excluded. Following review, teaching to AMU was delivered and a wall poster of the ‘ICARE’ framework was displayed. A second prospective cycle was performed reviewing deaths from March-September 2022. Results 50 deaths were recorded in cycle one. 21% (12/58) of dying patients were not prescribed EOL medications. Medication omission for 50% (6/12) of patients were due to lack of recognition of EOL. Other reasons included no consultant review, undecided resuscitation status and a missing prescription. In cycle two, 11% of dying patients (6/48 patients) were not prescribed EOL medications, all of which were due to lack of recognition of EOL. 12 deaths had EOL medications prescribed but had an inappropriate resuscitation status. Conclusion The second cycle showed a 50% reduction in deaths with EOL medication omissions, when compared to the first cycle. Reasons for medication omissions were less varied in cycle two, highlighting reduction in avoidable causes. Although not affecting patient care, a notable number of patient records had incorrect resuscitation statuses. Overall, improvement in delivery of EOL care within AMU can be seen. Future considerations involve emphasis on keeping electronic patient record up to date to avoid errors and continual provision of education to new and rolling staff.

Introduction Factors contributing to frailty result in increased hospitalisations, with 5- 10% of patients attending Accident and Emergency department living with frailty, and 30% of those patients admitted to acute medical units (Conroy, 2013). Hospital admissions result in functional decline and deconditioning (Get It Right First Time, 2021). The number of people in the UK over the age of 85 is set to double in the next 20 years and treble in the next 30 (Office of National Statistics, 2013). Their needs are best met in the community with a multi-disciplinary approach. Method Patients, residing in Benfleet and Leigh-on-sea, discharged from Geriatric wards at Southend Hospital were identified during ward MDT meetings. Inclusion criteria: • Recurrent admissions • Prolonged hospital stay • Clinical Frailty Score > 5 • Social support Using this criteria, 216 patients were included. 7 day readmission and 30 day readmission data was collected and compared to readmission rate prior to intervention. Intervention On discharge patients were linked with Frailty Nurses within their Primary Care Network and were reviewed within 48- 72 hours of discharge. Community support was provided via MDT, with involvement from consultant geriatrician. Concerns that could result in readmission were highlighted during these meeting, with patients being seen in Day Assessment Unit for review of sub-acute frailty syndrome if appropriate. Results Following intervention of utilising community MDT there was a reduction in rate of readmission. 9 patients (4.1%) were readmitted within 7 days of discharge and 14 patients (6.4%) were readmitted within 30 days, in comparison to 7.6% and 19.3%, respectively, prior to commencement of MDT. Conclusion This concludes that utilising community MDT with review following discharge has positive impact in reducing readmission rates. Highlighting potential risks of readmissions allows the MDT to address issues within the community and use bridging services appropriately.

Introduction

Advance care planning is a cornerstone of holistic care in patients with dementia. I conducted a quality improvement project (QIP) in Musgrave Park Hospital on the Orthogeriatrics Ward. The QIP focused on advance care planning in patients with moderate to advanced dementia.

Method

The target cohort was post-operative fracture patients with a formal diagnosis of dementia. Patients with moderate to advanced dementia were identified using the clinical frailty scale. Once a patient was identified, I ascertained whether the patient had capacity. If the patient was not deemed to have capacity, questions were deferred to the next of kin (NOK). The patient or NOK was asked ‘if an ACP was in place?’ and if an ACP was not in place, they were the asked ‘if they were aware of what an ACP is?’.

Results

I collected data between 1^st March 2023 and 1^st April 2023. Eighteen patients were identified. No patients were deemed to have capacity and therefore, all questions were deferred to their NOK. No patients had an ACP in place and only one NOK was aware of what an ACP is.

Conclusion

The data collected showed that no patients had an ACP in place and that there was a significant lack of education regarding what an ACP is. This lack of understanding concerning what an ACP entails may be preventing ACPs from being completed in the community. I designed a leaflet which summarised the key aspects of advance care planning. These leaflets will be handed out to patients or their NOKs. I will follow up on these patients to see if education has led to an ACP being put in place.

Introduction

AFU aims to provide Comprehensive Geriatric Assessment to frail, older service users.  A key component is Medication Review.

Patients living with frailty are more susceptible to medication side-effects and are often on Falls Risk Increasing Drugs (FRIDs¹) and medications with Anticholinergic Burden (ACB²) effects, which can cause falls/confusion/delirium/hallucinations. Aiming to reduce inappropriate polypharmacy, ACB and FRIDs scores, and optimise bone health is therefore essential.

Data highlighted only 17% of patients received Medication Review by a Pharmacist, which needed addressed without additional resources.

Method 

Medication Review usually involves a Pharmacist working alone and can be a lengthy process. We suggested a team approach with preparation and clinical details brought to a focused meeting with decisions made collectively.

After identifying key stakeholders, we introduced a focused Medication Review meeting twice weekly. 

Aims of review: reduce ACB and FRIDs scores, discontinue medications no longer indicated, improve bone health with a patient-centred approach throughout.

We produced a data collection form for audit purposes, and agreed how to communicate suggested changes to patients and other staff. 

Results

109 patients audited from October 2022-March 2023.

Medication Reviews increased from 17%-69%.

Improvements noted: average number of medications reduced from 9.5-9.0 (reduction diminished by addition of bone optimising medications³), number of patients with ACB ≥3 reduced from 32-11, average ACB score reduced from 1.9-0.9 and FRIDs score from 5.5-3.4.

ScHARR⁴ potential cost avoidance for 557 interventions was £37,501 - £86,218 with an average of 5 interventions/patient.

Conclusion 

A focused multidisciplinary Medication Review led to a reduced ACB and FRIDs score, with a potential saving from interventions. It also increased the number of patients receiving a Medication Review.

This innovative way of providing Medication Review makes best use of our time and skills, encourages education, and promotes conversations with patients/families about medications to see what matters to them.

References

1.  FRIDs (Falls Risk Increasing Drugs)

Northern Ireland Medicines Optimisation in Older People (MOOP)

2.  ACB Calculator

Available at: https://www.acbcalc.com/

3.  FRAX® Fracture Risk Assessment Tool

Available at: Frax.shef.ac.uk. (2023)

4.  ScHARR Potential Cost Avoidance

Karnon, J.; McIntosh, A.; Dean, J. et al. Modelling the expected net benefits of interventions to reduce the burden of medication errors. J. Health Serv. Res. Policy 2008, 13, 85–91.

Introduction

Using a patient centred, valued based health care approach to reshape the acute frailty unit with the University Hospital of Wales. Our multi-disciplinary team provide our patients with a compressive geriatric assessment. The goal is to ensure our patients are treated in a timely, thorough manner to avoid deconditioning and hospital induced harm. We want our unit to be guided by the needs of our patient population.

Methods

A redesign of the service structure within the acute frailty unit was undertaken as a result a patient survey taken in 2021. The aim was to focus on concerns that patients had highlighted within their feedback; noting particular challenges with length of time spent within the accident and emergency department, access to analgesia and continence needs. We were able to note these concerns and work on redesigning our care model to focus on meeting these needs.

Results

Following these changes, we undertook focused interviews with patients. They speak positivity about their stay within our acute frailty unit; noting they feel listened to about their goals, they are kept up to date with their treatment plans and that the staff genuinely care. They continue to be concerned with regards to access to emergency ambulances and length of stay within the accident and emergency department.

Conclusion

Further significant changes have been made to the service structure following additional patient feedback. Our number of beds within the acute footprint of the hospital have been increased from 12 to 19. We hope that this, alongside a streamlining of the complete admissions process within the University Hospital of Wales, will allow us to continue to provide patient centred, valued based health care to our patient population.