CQ - Patient Centredness

Introduction: One of the key action areas of the World Health Organization (WHO) third Global Patient Safety Challenge ‘Medication Without Harm’ (WHO, 2017) is to reduce severe avoidable medication-related harm and address polypharmacy. NICE guidance on falls risk assessment and prevention also includes medication review as part of its recommended multifactorial risk assessment (NICE, 2013). Use of Falls Risk Increasing Drugs (FRIDs), along with polypharmacy and anticholinergic burden (ACB) are known to increase the risk of falls, particularly in older people.

Method:

This research quantitatively evaluates the impact of the intervention of a novel community falls pharmacist role on medicines optimisation, in relation to FRIDs in older people who have had a fall. We will present data on admission and discharge from the service in relation to:

• Number and type of FRIDs prescribed
• Calculation of Anticholinergic Burden score using the ACBcalc® (King and Rabino, 2022)
• Polypharmacy- number of medications prescribed
• The appropriateness of medicines prescribed
• Undertake measurement of lying/ standing manual blood pressure to identify potential postural drop in blood pressure, and hypertension.
• Undertake a Bone health review using an approved tool (FRAX)
• Outcome of pharmacist referral of appropriate patients for DEXA scan using a new direct referral system
• Measure the significance of clinical interventions (EADON graded)
• Calculate the cost avoidance of pharmacist interventions (ScHARR Tool) Results

Results:

Data was collected on 92 patients over 14 months. Results indicate a medicines review by the community falls pharmacist leads to a statistically significant reduction in polypharmacy (¯8%; p<0.05) and ACB (¯33%; p<0.05), an increased appropriateness of prescribing (MAI ¯56%; p<0.05), 317 clinically significant interventions, identification of blood pressure issues (22%) eg orthostatic hypotension, and identification of osteopenia (n=13) or osteoporosis (n=4) using a new pharmacist DEXA referral pathway. Amitriptyline was the most common FRID deprescribed (22%). Annual cost avoidance due to pharmacist interventions were in the range of £28160 – £62358 along with drug cost savings of £6041, amounting to total savings of £34201-£68400, and invest to save return of one to two pounds for every £1 invested. Benefit to the environment of reduced inappropriate prescribing amounted to almost 1 tonne of avoidable CO₂ emissions per year.

Conclusion:

Introduction of a community falls pharmacist role is an effective and cost efficient means to optimise medicines in older people who experience falls, as well as having a positive impact on the environment.

Introduction

We plan fast-track discharges when a person has limited life expectancy and is reaching end of life. When such patients are identified, we use a simple fast-track tool to minimise the delay and reduce the need for in-depth assessments and paperwork. Despite being used very widely, there is very little data in literature regarding the indications for fast-track discharges and life expectancy of patients following discharge. We conducted this observational study to answer these questions.

Methods

We collected data over a three month period from the fast-track applications focusing on indications, length of survival post discharge and what has been communicated to the families.

Results

There were 45 discharges during the three month period. The mean age was 79.6 (range 32 – 98). Most of the applications were made from the medical wards (32), especially from the care of the elderly wards, followed by surgical and the emergency quarter. 10 patients died in the hospital before their discharge could be processed. 17 patients went home, 14 went to a care home and 4 went to a community setting. 23 patients had malignancy, 11 had end organ failure, 6 had advanced dementia, 3 had stroke and 2 had fracture neck of femur. After excluding the patients who died in the hospital, the mean survival following discharge was 15.9 days (1-77 days) and 5 patients were still alive at 90 days. Evidence for good communication with families was lacking from the application forms.

Discussion

Malignancy is the most common reason for fast-track discharges. Even though many patients and families think that end of life means only days or weeks, many survive much longer. We need better documentation regarding communication with patients and families regarding diagnosis and prognosis. 

Introduction

The term ‘frailty’ is increasingly being used in clinical practice. NHS services established to assess frail older people are described using various names including ‘Frailty Unit’ (FU). Little is known about patient’s self-perception on being frail and their views on the use of these terms and nomenclatures. Following the development of a new FU in the Emergency Quadrant of our DGH, this study was undertaken to assess how elderly in-patients in the unit perceive ‘frailty’ as a concept. Their views on the nomenclature of the unit and the service were also evaluated.

Methods

A semi-structured qualitative interview was conducted on in-patients in the FU after medical optimisation of their condition and prior to discharge. Those with communication barriers and lacking mental capacity to participate were excluded. Frailty severity was assessed using the Edmonton Frail Scale (EFS).

Results

20 patients were interviewed (mean age 84 years; range 75-98; 65% females). EFS classified patients (n) as ‘not frail’ (2), ‘vulnerable’ (7), ‘mild frailty’ (4), ‘moderate frailty’ (4) and ‘severe frailty’ (3). There was no correlation between age and presence of frailty on EFS. Only 5 (25%) considered themselves as frail compared to 55% deemed to be frail on EFS. Only 28.6% with moderate to severe frailty on EFS considered themselves as frail. 40% disapproved the nomenclature ‘Frailty Unit’ due to its negative connotation despite overall satisfaction with the service. Majority (85%) were happy to discuss the concept of frailty and strategies to manage it.

Conclusion

Identification of frailty on EFS may not necessarily correlate with the patient’s self-perception of being frail. Though the term frailty and frailty unit may be perceived as negative by some patients, this did not correlate with their service experience. Clinicians must take the opportunity to discuss the concept of frailty openly with patients including management strategies.

Introduction

During the COVID-19 pandemic, restricted hospital visitation policies were implemented to reduce the spread of the viral infection. As a result, telephone has become the main communication method despite the complexity of the elderly patients' medical and psychosocial issues. This has heightened anxiety and reduced satisfaction among patients and their families. This quality improvement project aimed at improving communication with patients' families. We introduced several strategies with the aim to update patients' families within 48 hours of admission and then at least once a week during patient's journey from admission to discharge.

Method

Retrospectively, all patients who were admitted to the ACM ward during the study period were included. Multiple Plan-Do-Study-Act (PDSA) cycles were implemented. As the first intervention, we added a new section on "Update patients' families" in our weekly harm free care document to identify patients' families who were not updated. Also, reminder emails were sent to all medical doctors to ensure that we record all discussions with families using "Discussions with patients and families' document". As the second intervention, a poster on "Harm Free Thursday and Update Friday" was displayed in the doctor's office. Face-to-face education was provided to new trainees to emphasise the importance of good communication with patients' families. Data was collected from electronic patient record (EPR) and Microsoft Excel was used for data collection and analysis.

Results

189 patients were included in the baseline audit which showed that only 49% of patients' families were updated weekly throughout the admission. Compliance in communication with families after the first and second cycle was 62% and 69% respectively. Following the second PDSA cycle, the percentage of patients' families who were updated within 48 hours of admission increased from 50% to 56%.

Conclusion

The project showed significant improvement in communication with patients' families with each cycle.

Introduction

Increased frailty is associated with increased post-operative morbidity and mortality in older patients undergoing emergency laparotomy. NELA recommend documentation of frailty in surgical patients over 65.

Using QI methodology, we introduced a ‘CARE tool’ for surgical doctors aiming to improve their documentation of an older person’s medical history (including CFS and delirium).

Method

A collaborative team representing geriatric medicine, anaesthetics and surgery devised the acronym CARE (Cognition, Assistance at home, Record the CFS, Exercise tolerance).

The tool was tested using QI methodology over 2 PDSA cycles. Cycle one introduced the tool into electronic patient records (EPR) and presented it at the surgical faculty meeting. Cycle two introduced the tool specifically to surgical FY1 doctors during induction.

The EPR surgical clerkings of patients over 65 years old admitted to general surgery were sampled weekly over seven weeks to assess CARE tool completion.

Post-intervention, we surveyed the surgical doctors assessing their understanding of frailty and perceived value of the CARE tool.

Results

At baseline: 12% of confusion, 92% dementia status, 0% CFS, 30% assistance at home, 8% exercise tolerance were documented.

Following PDSA cycle one, use of the CARE tool was 40%. There was an increase in the documentation of confusion (40%) and CFS (40%). Dementia status and assistance at home were documented in similar frequency pre and post-cycle.

During cycle two, CFS documentation increased to 55% but identification of confusion dropped to 25%. The survey demonstrated that frailty, CFS scoring and delirium screening were better understood by junior doctors than Consultants and registrars.

Conclusions

Our project showed mixed success in improving documentation using the CARE tool. The survey demonstrated a good understanding and knowledge of frailty in surgical FY1s. Ongoing frailty teaching is planned for the surgical department.

Background Acutely unwell hospitalised older people have better outcomes including mortality and functional status when CGA (Comprehensive Geriatric Assessment) is performed. A previous complaint, escalated to the Scottish Public Services Ombudsman, highlighted issues with CGA documentation and recording MDT discussion. This pilot project’s aim was to create a method for documenting CGA MDT plans and to embed this as routine practice for all inpatients on a Geriatrics ward. Method Following consultation with staff on this ward, a sticker was developed detailing status of medical and therapy input, planned discharge date and likely required support on discharge to evidence MDT discussion. This was completed weekly at the boardround for each patient. The stickers were implemented over a 2-week roll-out phase, and use (and completion) of stickers were compared to a 2-week period approximately 1 month later. Feedback from ward staff was also collected via questionnaires. Results Initially, 98% of patients had a sticker completed (n=49/50) and 86% of all required information was documented (n=43/50). For the second round of data collection this fell to an 18% completion rate (n=7/38). Ward staff interviewed were aware of the stickers and felt they improved CGA communication (n=100%, n=8/8). Suggestions for improvement included an option to record whether families were updated, clearer options for discharge status and reasons why a patient may not have received occupational or physiotherapy. Conclusion The CGA board round sticker was a positively received, simple and effective intervention to improve documentation. It addressed an area which had been highlighted as requiring improvement. As expected, initial completion rates were high but rotation of staff impacted on subsequent completion rates. Establishing this as routine practice will be challenging but permanent staff present at the boardround will facilitate allocation of this task and a poster highlighting this process has been displayed on the ward.

Can use of sensor technology prevent hospitalisations in frail older people at high risk of hospital admissions?

Background

There has been significant developments, investment and ambition to use modern technology in admission avoidance in hospitals. Sensor technology has been one area of development. We used My Sense to improve outcomes for a cohort of High Intensity Users (HIU) frail older patients, and compared hospitalisation rates before and after employing Sensor technology. HIU patient consent criteria is 3 Admissions with 40 days Length of Stay.

Introduction

MySENSE

• 8 Sensors placed around the home
• Chargeable wrist device
• Monitors - activity, heart rate, environment temperature

Aim

• To detect change in health and routine
• Reduce deterioration in physical and mental health well-being
• Promote independence
• Unnecessary Admissions

Methods

 Fifty randomly selected HIU patients consented to use My Sense from November 2021 to June 2022.  HIU monitors usage via a dashboard with the aim to intervene and reduce the likelihood of deterioration caused by inactivity or illness.  HIU contacts the key responders, include liaising with family members, GP, other health/care professionals if unusual patterns or no activity is recorded. For example - bed/chair/toilet/kettle/tap sensor not being activated for some time. Indicators for potential UTI’s, constipation, dehydration, reduced mobility and other conditions if not addressed may result in admission.

Results

• Admissions prior to installation 84 post 54
• Length of Stay prior to installation 909 post 724
• Cost saving = £64,750.00
• Cost of equipment £399 with a monthly subscription fees £39.99 per month

Conclusion

• Useful to detect any changes to normal pattern improving patient safety
• Early identification of deterioration and early deployment of help for earlier intervention
• Raised patient, family and staff satisfaction/reassurance
• Reduced reliance on acute care
• Reduced level of physical social care support / greater independence
• Useful tool but more detailed studies are needed.

Introduction

Our perioperative service for older people undergoing surgery (POPS) commenced preoperative assessment of co-morbid and frail patients undergoing elective orthopaedic surgery in 2021. As part of the comprehensive geriatric assessment (CGA) and shared-decision-making process (SDM), we wanted to analyse the decisions our patients made around surgery and how many regretted having surgery.  

Methods

• Review of all orthopaedic patients seen by POPS between September 2021-December 2022

Intervention

• CGA and SDM on all patients
• Data collected: comorbidities, Clinical Frailty Scale (CFS), SDM outcome.
• Decision regret scale was sent out 6 months post op from August 2022.

Results

• 111 patients assessed. Median age 89 (range 60-97). Median CFS 4 (range 1-7)
• Median comorbidities 12 (range 2-22).
• Surgery considered: knee 43%, hip 33%, shoulder 10%, spine 6%, revision hip 5%, and revision knee 3%.
• 77% wanted to proceed with surgery and 13% did not after SDM. 5% were deemed not fit enough and 5% are still awaiting final decision outcomes.
• Decision regret data has been returned by 10/14 (71%) of patients who proceeded. None regretted their decision. 

Conclusion

The majority of patients seen by POPS wish to proceed with orthopaedic surgery. However, 13% did not wish to proceed following SDM which is similar to the 14% of patients who regretted undergoing surgery in other settings¹. Of those that have returned the 6-month post op questionnaires, none have regretted their decision. Understanding how optimisation and appropriate SDM impacts on the patient experience is important as frailty impacts adversely on patient reported outcomes in elective hip and knee surgery. Frail patients are also less likely to report their postoperative outcomes in national data sets compared to less frail patients².

1. CPOC website
2. Cook et al (2022). The impact of frailty on patient reported outcomes following hip and knee arthroplasty. Age and Ageing.

Introduction

The British Geriatrics Society and NHS England recommend that patients aged 65 and over should be screened for frailty when presenting to healthcare services to facilitate early comprehensive geriatric assessment (CGA). Recognition of frailty frequently relies on assessment by FY1s. We sought to assess a) how confident FY1s are in recognising and managing frailty, b) their understanding of CGA, and c) how these change during the year.

Methods

Questionnaires (quantitative and qualitative data) were given to FY1s at induction, 6 months, and 12 months. Teaching sessions on frailty and CGA were delivered. We collated feedback on how frailty recognition and CGA knowledge had altered their assessment of older people.

Results

All FY1 Doctors completed the survey at induction. The 6 months and 12 months surveys were emailed to FY1s. The survey response rate was 100% (31/31), 68% (21/31) and 58% (18/31), respectively. At induction, 23% (7/31) reported they were “quite” or “very” confident in assessing for frailty. This increased to 71% at 6 months and 100% at 12 months. Fifty-two per cent (16/31) of FY1 Doctors were aware of a tool to assess for frailty at baseline, increasing to 100% (18/18) at 12 months. Knowledge of CGA improved less, from 48% (15/31) at baseline to 83% (15/18) at 12 months. There was no association between speciality experience and confidence levels. Feedback from FY1 doctors indicated that frailty recognition allowed identification of patients who may benefit from advanced care planning discussions and triggered early therapy input.

Conclusions

Despite BGS and NHS England recommendations, at induction, FY1s lack confidence in frailty recognition and assessment. Through experiential learning and targeted teaching this improved, not limited to those in geriatric medicine. We recommend final year medical students need increased frailty and CGA specific education to improve their confidence when assessing frail older patients.

Introduction
As part of a planned care initiative undertaken with the Bevan Commission to improve surgical waiting lists in Swansea Bay we contacted patients on the waiting list for a cholecystectomy, undertook frailty screening and invited those with frailty markers to undergo clinic based geriatric assessment . Clinical governance requires patient input into the setup of any service (1). A patient satisfaction survey following clinic, along with a patient focus group were conducted. Methods 27 patients completed an online survey regarding their experience at clinic. 8 patients attended the focus group, all had attended clinic. Those we hadn't seen face to face declined or were unable to attend. The group was run by a team who were independent of the project, recorded on teams and transcribed. Results Post clinic survey 100% (27/27 patients) knew why they were invited to clinic, >80% found it useful and 92% felt their health needs were covered. The focus group highlighted a number of issues regarding frustration with administration of the list, feeling ‘forgotten about’ and as though they ‘didn’t matter’. They attended multiple pre-op assessments but had no communication, they felt our clinic was their first meaningful clinical contact.

Conclusions

Patient reported experience is a key part of service development however bias is often evident. (2) It was clear that patients valued the face to face aspect of clinic and the focus group. One clear theme from our focus group highlights administration and communication which are potentially modifiable within our resources. A theme of desiring patient choice and continuity of care between specialities was evident, which we hope to address with a unified pathway for perioperative care. 1) Clinical governance - GOV.UK (www.gov.uk) 2) The use of focus group discussion methodology: Insights from two decades of application in conservation, T O Nyumba. 2018