CQ - Patient Centredness

Introduction:

Urinary incontinence, one of the original geriatric giants, is frequently overlooked despite its potential for reversibility and profound impact on older adults. The purpose of this audit was to evaluate the prevalence of continence and utilisation of incontinence wear among inpatients in a rehabilitation facility.

Methods:

Continence care quality in a medical gerontology ward was evaluated using the Royal College of Physicians (RCP) National Audit of Continence Care (NACC) standard. A prospective audit was conducted over a five-day period, documenting continence wear and urinary continence. Two interventions were implemented before re-auditing: incorporating continence as a teaching topic in the non-consultant hospital doctor (NCHD) teaching schedule and adapting the multi-disciplinary team (MDT) proforma to include patient-specific continence records. A snapshot re-audit was then conducted to assess any improvements resulting from these interventions.

Results:

The initial audit included 31 patients, with 26 (83.9%) wearing incontinence wear, of whom 21 (80.8%) opted for it voluntarily. Urinary incontinence was documented in 13 patients (41.9%).

In the re-audit, 40 patients were included, with 27 (67.5%) wearing incontinence wear, of whom 19 (70%) made the choice. Urinary incontinence was documented in 18 patients (45.7%).

Conclusion:

The re-audit revealed a slight decrease in incontinence wear usage (67.5% compared to the initial rate of 83.9%). Many patients wearing incontinence wear expressed a consistent preference for it in both audit cycles. The prevalence of urinary incontinence remained relatively consistent between the initial audit (41.9%) and the re-audit (45.7%).

The persistent prevalence of urinary incontinence calls for effective strategies to address this issue. Furthermore, the patients' preference for incontinence wear underscores the significance of engaging both the MDT and the patients themselves in future interventions. Future projects should focus on gaining a deeper understanding of patients' perspectives on continence care and evaluating the impact of incontinence on patient outcomes.

Introduction: Across the UK, emergency and assessment units are faced with the challenge of streamlining urgent care services which best meets the requirement of older frail patients.

Method: Patient pathways were mapped using real-time and retrospective data collected from the notes of 30 frail patients over 75 admitted to ED under medicine. Frail patients were identified by the Frailty Intervention Team, and patient demographics were noted. Key touchpoints and the date/times of initial treatment and investigations were documented. Experience questionnaires produced by the Acute Frailty Network were completed to capture the perspectives of 38 frail patients over 75.

Results: Of the 30 patients admitted to ED, 21 (70%) had cognitive impairment and 16 (53.3%) patients had a frailty score (FS)>4. The median time spent in ED/AU for the cohort was 95 hours 31 minutes (approx. four days). The median trolley wait for the cohort was 30 hours 42 minutes (IQR 17hr 42 min-48hr 22 min), 34 hours 22 minutes for patients with cognitive impairment and 28 hours 17 minutes for patients with FS>4, which were significantly longer than the one-hour Silver Book standard. Of the patients admitted during the day, the CGA was performed within 24 hours 9 minutes (IQR 21hr-41 hr) of admission, which does not meet the Silver Book standard of one hour. The median number of night transfers within ED/AU was 1, with 51.5% done at night. Questionnaire results highlighted suboptimal environments, with over 50% of patients feeling indifferent or unhappy during admission.

Conclusion: Both quantitative and qualitative data demonstrated challenging patient journeys in ED/AU. The crowded and busy environment of ED/AU needs to be more conducive to addressing the complex needs of frail individuals. Establishing an acute frailty unit within ED would provide rapid patient-centred care for frail patients.

The 2020-21 Chief Medical Officer report described Treatment Escalation Plans (TEPs) as ‘Realistic Medicine in action.’ Our aim is to increase TEP completion on the Medicine of the Elderly (MOE) wards at the Royal Infirmary of Edinburgh to >90% by July 2023.

Since August 2022, we collected weekly data from a single MOE ward. In October, we upscaled to include four MOE and one stroke ward. The notes of five randomly selected patients were reviewed weekly to see whether they have a TEP, and if so, which parts were completed. To further understand behaviours around TEP completion, we collected qualitative data asking doctors what the triggers and barriers were to TEP completion. 40% found the conversations challenging whereas 30% cited time and environment as barriers. We used this data to generate change ideas. For PDSA cycle 1, we developed a teaching session around TEP conversations. This is delivered regularly to all junior doctors and ANPs in the department. For PDSA 2, we allocated a weekly ward ‘TEP champion’ to highlight patients without a TEP and encourage completion.

Median for TEP completion was 75% on the initial ward, 42% over the four MOE wards and 20% for the stroke ward. All patients with a TEP had their resuscitation status documented. One third of patients did not have a TEP at all. Of the two thirds of patients with a TEP, a quarter were incomplete. Sections on goals of care, communication and interventions were completed in around half.

This project is ongoing with future PDSAs planned to address the barriers of time and environment. PDSA 3 will test the introduction of a mobile TEP phone to enable discussions in a quieter environment. The variation in practice in MOE versus stroke is important and requires further understanding of the barriers specific to stroke.

 Introduction: Indwelling urinary catheters (IUC) are well-known to cause serious adverse outcomes in older adults; such as catheter associated urinary tract infections (CAUTI), direct trauma, delirium, deconditioning, falls, restrain, prolonged length of stay etc. (Lee E., Malatt C, 2011). Removal of IUCs as soon as the indication is resolved, results in better outcomes (Dawson et al, 2017). We identified high rates of inappropriate catheterisations as a regular practice or part of sepsis protocol in our hospital. This QIP was designed to compare our practice against the standards set by NICE and Royal College of Nursing.

Methods: Two PDSA cycles of 30 patients each, were completed between 2021-2022 (4 months apart), in Acute Frailty Unit and two Elderly Care wards. New IUCs in patients above 65 years were included. Data were collected on, documentation of IUCs, indications, plans for Trial without catheters (TWOC), appropriate management plans and CAUTI. Interventions post first PDSA cycle were; organised teaching to the nurses and doctors, discussing catheters at by-daily board rounds (BR), displaying flowcharts and reviewing IUCs during ward rounds.

Results: Documentation of IUCs improved significantly from 17/30 to 24/30. There was a small reduction in inappropriate indications from 16/30 to 12/30. Documentation of TWOC plans improved from 4/30 to 11/30. Collection of urine samples for CAUTI’s improved from 11 to 18. Our interventions were shown to produce positive outcomes.

Conclusion: Despite continuous education and BR discussions, there’s still room for improvement. Better understanding of catheter associated harm by frailty teams resulted in positive outcomes. Next steps prior to the 3rd PDSA cycle include educating Emergency and medical teams through wider teaching platforms and integrating changes to hospital electronic systems on appropriate documentation and TWOC plans. Our study would be applicable in similar settings nationally and globally to achieve better catheter care in older adults.

Introduction

The Covid19 pandemic represents an unprecedented challenge to global health and care services and necessitated a rapid shift towards healthcare being provided remotely.¹ A quality improvement project was conducted in Cardiff CRT to improve staff confidence in relation to remote-working to optimise the care of older patients in the community.

Objectives

• To integrate the use of technology in intermediate care in Cardiff CRT

Method

A survey was sent to Cardiff CRT staff in May 2020. The plan-do-study-act (PDSA) model was used to implement improvement interventions whilst allowing continuous service delivery. These included investment in hardware, updated software, a daily team huddle, increased transparency throughout the Multidisciplinary Team and stricter referral criteria. A follow-up survey was conducted in February 2022.

Results

Three key areas for improvement were identified: i) access to resources ii) team communication and iii) access to information.

The majority of respondents (62%) had no experience of remote-working prior to the Covid19 pandemic. Now, telephone consultation (50%), video consultation (19%), email (23%) and other technology (8%) are regularly employed. Self-reported confidence has improved in relation to remote-working.

Most respondents (56%) reported improved time-management and flexible working (30%) as the primary advantages of remote-working. Isolation from team members (44%) and barriers to communication (44%) were cited as the main disadvantages. 75% of respondents anticipate changing the way they work due to skills learnt during remote-working. Job satisfaction is now lower, however many recognised this was due to pandemic sequelae and other extraneous factors.

Conclusion

• Majority of staff have learnt additional skills and improved confidence in remote-working
• All staff now employ remote-working in Cardiff CRT and most plan to continue post-pandemic
• Further training needs have been identified in the virtual intermediate care setting
• Team communication and isolation remain an issue
• Job satisfaction has declined during the pandemic

References

¹ Nuffield Trust

Disclosure of interests: None

Key Words:

Covid19, Frailty, Older People, Community, Intermediate Care, Technology

Introduction: One in three hospitalised patients die within 12 months of admission, rising to 45.6% in individuals aged 85 and older. Resuscitation is rarely successful in this patient group. Most older persons are happy to engage in discussions regarding resuscitation and patients' and relatives' involvement is recommended by the General Medical Council and Royal College of Physicians.

We aimed to increase the number of resuscitation and escalation of care discussions across our Ageing and Complex Medicine department to 90% by November 2022.

Method: Retrospective review of randomly selected electronic case notes for patients discharged in August 2021, November 2021, March 2022, August 2022 and November 2022, to determine when resuscitation was discussed and, if not discussed, the reasons why. Interventions included: 1. face-to-face presentation of findings with discussion at departmental teaching, 2. distribution of posters on each ward, 3. discussion between each ward team, to review individual wards results.

Results: 388 patient cases were reviewed over 5 data collection cycles. At baseline, in August 2021, 49% patients had discussion surrounding resuscitation, increasing to 69% following intervention 1 (November 2021) and 79% following intervention 2 (March 2022). Follow up in August 2022 showed this increase was not sustained, falling to 64%. After intervention 3 (November 2022) this rose again to 72%. August 2022 data was evaluated to identify reasons behind no discussion. The main reason was 'good baseline' (31.1%) with no documented reason in 48.3% cases.

Conclusion: Percentage of resuscitation discussions has fluctuated over time, improving following targeted intervention but has not reached 90%. The main barriers to success identified included junior doctor change-over, fast patient flow, competing ward priorities and patients'/relatives' lack of understanding. We hope to integrate teaching regarding resuscitation into our departmental induction, to sustain knowledge and understanding within the workforce.

Background

Up to 17.5% of admissions for older adults with frailty may be Preventable Emergency Admissions (PEAs). PEAs are costly and expose patients to complications including deconditioning, delirium, malnutrition and nosocomial infections. Royal Derby Hospital (RDH) has 1159 beds and cares for a population of around one million. The Frailty Emergency Assessment Team (FEAT) operates within the Emergency Department (ED) and Medical Assessment Unit. FEAT is multi-disciplinary, comprising nurses, physiotherapists and occupational therapists.

Aim

To reduce the number of PEAs for older adults presenting to RDH.

Design

We integrated a Geriatrician into FEAT with the aim of reducing PEAs through early medical reviews. Suitable patients were identified through referral from ED and routine screening of the patient information system. To support consistent medical reviews and automate data collection we created an e-form embedded within the Electronic Patient Record. This captured details and outcome of medical reviews including Clinical Frailty Score (CFS), problem list, medication review and ‘Medically Stable for Discharge’ (MSFD) status.

Results

Between 7th February 2022 and 20th February 2022 68 medical reviews were collected on the e-form. 72% were assessed first by an ED clinician. 81% had a CFS of 5-7 and 7% had a CFS of 8. The most common presenting complaint was ‘fall(s)’ (25%) followed by ‘clouded consciousness’ (13%). 66% of FEAT physician reviews resulted in planned discharge from ED, 13% of which avoided an admission planned by ED. Of 68 patients reviewed 42 (62%) were MSFD. Of these 29 (69%) were discharged home, 11 (26%) were admitted to a ward to await interim beds or new care package, one (2%) patient was discharged to a care home and one (2%) to another health care facility.

Conclusion

Our intervention reduced PEAs for older adults presenting to RDH. The e-form automated data collection successfully.

Introduction: The Enhanced Health in Care Homes Framework recognises personalised advance care planning (ACP) as a key component of optimal healthcare for care home residents ​(1)​. Documented ACP discussions guide decision-making in acute situations and may facilitate avoidance of inappropriate hospital admissions. Methods: We established a multidisciplinary care home service which aimed to provide comprehensive geriatric assessment (CGA) based ACP to all residents within three pilot care homes. We evaluated the effect of proactive, systematic CGA and ACP. Ambulance call-out and conveyance data for the pilot care homes were compared for three months before and after our intervention. Results: 122 residents were reviewed during the pilot period and 61 new ACPs were completed. Amongst the 61 new ACPs, 41 new decisions were made during the pilot to avoid future hospital admission and to prioritise comfort in the community. Total ambulance callouts to the 3 pilot care homes were observed to fall from 55 to 33 in the 3 months following our intervention: a reduction of 40%. Additionally, when an ambulance attended the scene, conveyance to an acute hospital was observed to fall by 50% (pre-n =40 vs post-n=19), in favour of discharging into the community. Conclusion: The provision of systematic CGA-based advance care planning in care homes may be associated with a lower frequency of ambulance call-outs and lower rates of conveyance of care home residents to hospital. Proactive advance care planning may influence GP, care home, and paramedic decision-making.

​​1. NHS England and NHS Improvement. The Framework for Enhanced Health in Care Homes. 2020 Mar.

Introduction:

Sleep is an essential requirement for good health. The hospital environment is often not compatible with adequate, restorative sleep. Disruption is multifactorial and affecting parameters can be environmental, physical, or psychological.

Aims:

To observe the difference in sleep quality in patients on medical wards compared with their baseline and highlight areas where sleep quality can be improved.

Methods:

This observational study analysed patients on four medical wards at Chelsea and Westminster Hospital. Inclusion criteria: Patients with good cognition who had been in hospital for over a week. We used a modified Jenkins sleep questionnaire in which patients’ sleep before and during their hospital stay was compared, assigning a score to each. Questions assessed how often in a week patients had difficulty sleeping, waking up too often or early, and feeling exhausted. The higher the score the worse the sleep quality. Patients were also invited to report factors contributing to sleep disturbances and make suggestions.

Results:

Overall, sleep quality was reduced in hospital. Across all patients, the cumulative modified Jenkins score increased by 70% from 144 to 245 (n =25). The mean sleep satisfaction score was 6.08/10, the range was 10, and the median was 7. The median score amongst both side rooms (n=10/25) and open bay patients (n=15/25) was equal (6.6). Amongst the qualitative data, common themes were identified: noise, light and overnight observations. Of the two patients who used eye masks/sleeping aids, both were very satisfied with their sleep. Similar findings are echoed in existing literature.

Conclusion:

Hospital admission is associated with worse sleep. The introduction of eye-masks and earplugs more routinely may improve sleep quality and prevent overuse of hypnotics, which can lead to potential complications. Additionally, optimising frequency of overnight observations, guided by patients’ National Early Warning Score may reduce interruptions amongst medically fit patients overnight.

Introduction
Person-centred care is recognised as best practice for the care of people with delirium or dementia. In Cardiff and Vale University Health Board (CAVUHB), “Read About Me” (RAM) documents are used to support person-centred care in these patient groups. However, there are significant barriers to their routine use in clinical practice (Clark, E, Wood, F, Wood, S. Health Expect. 2022; 25: 1215- 1231). We conducted a two-cycle audit investigating the use of these documents on geriatric wards in two acute hospital sites, and trialled two interventions to increase their usage.
Methods 

Both rounds evaluated patients on 9 acute geriatric wards at CAVUHB. Patients with a diagnosis of dementia or delirium were identified by ward staff and medical notes, which we also used to see if a RAM had been completed. Intervention one was the installation of noticeboards on geriatric wards encouraging RAM usage. Intervention two was the implementation of a ward admission checklist as well as engagement with CAVUHB “dementia champions” to advocate for their usage.
Results 

Taking the 9 wards surveyed individually, in round one, the median usage of RAMs was 25% (range of 0% to 55%), which improved to 33% (range of 15.2% to 66.6%) after our intervention. Re-evaluation 3 months later, prior to intervention two, showed that RAM usage had regressed (median 27.2%, range 0% to 50%). We will re-evaluate after intervention two.

Conclusions

Long-term improvement in RAM usage was not achieved after installation of noticeboards. This loss of drive may be due to the wearing off of the novelty of the noticeboards, leading to prioritisation of other clinical tasks. We believe a better approach could be to combine a checklist to reduce cognitive workload with engagement of dementia champions in order to improve RAM usage and therefore improve person-centred care.