CQ - Patient Centredness

Introduction

The UK Parkinson's audit assesses whether patients with Parkinson's Disease (PD) are managed according to standards. Referring patients to physiotherapy (PT) and advising those with daytime sleepiness not to drive are two of these. In our clinic, patients identified as drivers are advised to inform the DVLA and will undergo a MOCA, sleep questionnaire and driving assessment. 

Project Aim

Are we making early physiotherapy referrals and documenting driving status in newly diagnosed outpatients? 

Methods

Online notes of newly diagnosed patients over a 12 month period were reviewed. A clinic checklist was created and displayed in the clinic as a poster with the mnemonic:

Lasting Power of attorney

Driving

Osteoporosis

Physiotherapy

Anticipatory care planning

Following introduction of the checklist a further cycle has taken place. 

Results

In the initial cycle, 34 newly diagnosed patients were identified. 4 were nursing home residents and excluded from results. Of those remaining, 83% had documentation of driving status. 2 patients were drivers and one had evidence of completed driving assessments. 20 patients were referred to physiotherapy and a further 3 patients were offered (76%). 50% of referrals were within the first month of diagnosis. Following checklist introduction, 21 new PD patients were identified over 6 months. The clinic team were sent updated data throughout to encourage ongoing improvements. 95% had documentation of driving status. 9 were drivers. 6 had full driving assessment completed. 16 (76%) patients were referred to physiotherapy. 75% of these were referred within the first month.

Conclusions

Repeat data collection has shown improvement in both driving status documentation and early physiotherapy referral. The checklist reminds us of important aspects of outpatient care in PD that may otherwise get forgotten. Ongoing data collection will hopefully continue to improve. 

Introduction The Fracture Liaison Service (FLS) is a multidisciplinary service for individuals over 50 presenting with fragility fractures. It is designed to assess future fracture risk, and appropriately diagnose and manage patients with osteoporosis.1 At Wrightington, Wigan and Leigh Teaching Hospitals (WWL), concerns were raised that access to this service was poor, meaning some patients presenting with fragility fractures were not receiving appropriate management to reduce risk of recurrent fracture. This project was designed to increase referrals to the service. Methods A cohort was identified of patients over 50 presenting to WWL with a fractured proximal humerus or distal radius/ulna over a three-month period from January to March 2021. These presentations were reviewed to identify the proportion of these patients who had been appropriately referred to the FLS. Following the initial audit, the FLS referral pathway was reviewed, and discussions were held with multidisciplinary teams (MDTs) in radiology and orthopaedic surgery to highlight the importance of appropriate bone health risk assessment. The number of patients referred each week by radiology were assessed before and after these discussions to assess whether access to the FLS had improved. Results In the initial audit 4.2% of patients with humeral fractures (n=24) and 0% of patients with radial/ulnar fractures (n=29) were appropriately referred to the FLS. Mean weekly referrals from radiology to the FLS significantly increased following the MDT discussions (mean 6.14, SD 4.40 vs mean 22, SD 6.38; t=6.71 p001 conclusions pre-existing referral pathways to the fls were found be resulting in many patients not receiving appropriate care for their bone health. a simple review of pathways, and discussion with mdts other departments was way improving access therefore hopefully reducing risk fracture recurrence. references 1. https: />/theros.org.uk/media/1eubz33w/ros-clinical-standards-for-fracture-liaison-services-august-2019.pdf [Accessed 18.05.2022]

Advance care plans (ACP) in secondary care: What are the patient outcomes following discharge from hospital with an ACP?

Introduction:  Treatment escalation plans are discussed in hospital but not always communicated to community care on discharge, leading to avoidable admissions to hospital and hospital deaths which may be not what the patient wants. The project aimed to review what happened to patients discharged from hospital with an ACP over a 12 month period.

Method: Older person service (OPS) inpatients were identified for ACP discussions, using Clinical frailty score, presence of life limiting conditions, co-morbidities, significant decline. Over a 12 month period 155 ACP's were completed using the ACP document on the Trust electronic record (EPR), including the level of appropriate care and preference for location of on-going care.  On discharge copies of the ACP were sent with the patient, to their GP and to the ambulance service. EPR was used reviewed patients up to 12 months post discharge.

Results: Of patients with an ACP; the wish of all patients was to remain out of hospital and be cared for in the community; 63% were discharged to care home setting; 19% were readmitted as inpatients (v’s 43.7% Trust OPS/no ACP readmissions); 8% of patients died before discharge; 92% of patients who died after discharged, died out of hospital (v’s 47.5% Trust OPS/no ACP deaths); 25% were still alive at 12 months. The process of completing the ACP and communicating the ACP was found to be long and not user friendly with multiple steps and needed refining

Conclusion:  ACP's offer support to facilitate patient's wishes. The use of ACP's in secondary care benefits patients on discharge, it reduces readmissions and in-hospital deaths.  The current ACP document is lengthy and requires simplifying. This has led to a work group to redevelop the ACP into a more user friendly/shareable document, which will encourage on-going use of ACP's and can be adopted throughout the Trust

Introduction

The Norman Power Centre (NPC) is a 32 bedded Intermediate Care Unit, run by an acute hospital trust in Birmingham, UK, for patients who require ongoing 24 hour care, rehabilitation or further assessment, but do not need to be in an acute hospital setting. These frail patients attend numerous outpatient hospital appointments, but rarely do staff receive communication back from these outpatient reviews. This can lead to delays in implementing specialist management plans, with potential for adverse outcomes for patients and increased staff workload in seeking out the required information. A ‘Consultation Communication’ proforma was designed, to be filled in at the appointment and brought back to NPC with the patient.

Method

Patients and escorts took proformas to outpatient appointments between March and June 2022. The information on the forms was then analysed to assess completeness and usefulness.

Results

Appointments were in surgical and medical specialities, as well as imaging in 3 hospitals within 1 trust. Proformas were taken to 19/20 appointments. 100% of these were at least partially completed, with only 2 forms being largely incomplete. 17/19 provided information about the assessment carried out. 12/19 included recommendations relevant to admission at NPC. 13/19 had information on medication changes. 14/19 stated whether follow up was required. 8 out of 9 required follow-ups had specific details included. 13/19 had the professional’s details, 11 with contact numbers. Of those without details, 2 were imaging appointments where contact details were not relevant.

Conclusions

This easy to implement, simple intervention, with an excellent engagement rate from both NPC and outpatient appointment staff, has led to improved continuity of care for patients. The proforma has scope to be improved based on staff feedback, and its use could be expanded across other off-site facilities such as community hospitals or care homes.

Introduction:

Recurrent episodes of aspiration pneumonia (RAP) are a significant problem in frail patients leading to high re-hospitalization and mortality rates. Anticipatory care planning (ACP) enables improved quality of life and end of life care. We reviewed the assessment, ACP discussions and communication with Primary Care for patients admitted with RAP.

Methods:

We used PDSA methodology, reviewing patients with RAP referred to Speech and Language Therapy (SLT) in Elderly Medicine wards.

Educational interventions were implemented. An illustrative case and pre-intervention results were presented at an online hospital-wide seminar and subsequently at an online departmental medical teaching session. Our second round of interventions included departmental induction teaching for newly rotated doctors and the creation of an electronic ACP document (RAP ACP).

Post-intervention analyses were conducted after both rounds of intervention.

Results:

Baseline data was collected from 116 patients (mean age 85, 47% female).  Post intervention data was collected from 10 patients (mean age 88, 70% female) and subsequently 25 patients (mean age 88, 32% female).

Baseline data demonstrated need for improvements in Mental Capacity Assessment (MCA) documentation (21.5%), ACP completion (26.7%) and flagging patients suitable for Gold Standards Framework (GSF) on discharge (15%).

Following educational interventions, there was a substantial improvement in MCA documentation (80%) and completion of ACP discussions (70%). Communication of patients eligible for GSF remained similar (14.2%). 

Following our second interventions there continued to be improvement in MCA documentation (28%) and ACP completion (52.2%) although not as marked. Communication of patients eligible for GSF showed improvement (31.6%).  

Conclusions:

Educational interventions substantially improved the quality of individualised care provided in the short term. Mortality was high and further interventions targeting ACP completion and discharge communication are indicated.

A platform presentation to allow evaluation of diagnostics used in a Frailty Hospital at Home . An analysis of the data and a chance to explore the affect of diagnostics on subsequent hospital admissions or number of community team visits. Affect of diagnostics on management plans developed and whether they align with a person's documented goals. Data collected as part of an audit looking at the number of diagnostic tests taken by the Frailty Hospital at Home team. Subsequent outcomes including the number of hospital admissions, treatments started at home, subsequent number of community team visits and advance care planning were considered.

QIP topic was to improve emollient prescriptions for patients admitted to Elderly Care Unit as not all elderly care patients who are already prescribed emollients by General Practice through regular medication or current acute medication are being prescribed these when inpatient.

The aim of the QIP was: By April 2022 we will increase the number of emollient prescriptions for elderly care patients admitted to elderly care unit who are already prescribed these in general practice by 20% The QIP measures were identified which included % emollients correctly prescribed to relevant patients and number of emollient correctly prescribed to relevant patients on a run chart on LIFEQI. Use of QIP methodology demonstrated. Used EPR which is the electronic patient system to check that patient clerked into Elderly Admissions Unit were being prescribed their regular or current acute emollient. Change implantation in the first cycle included teaching doctors at handover the importance of emollient prescribing and putting up leaflets in the Elderly Admissions Unit. Data was then collected and plotted on a run chart to see if patients admitted to Elderly Admission Unit were being prescribed their regular or current acute emollients through the electronic patient system. Evaluation of change as seen by analysis data from run chart. Prior to intervention emollient prescription was at 47% then went to 76% after first intervention and hence aim of Quality Improvement Project achieved. Another cycle was done to ensure it was more sustainable and to increase emollient prescription further. This involved emailing the new doctors rotating into Elderly Care importance of emollient prescription and another teaching session. After the second intervention emollient prescription went up to 88%.

Introduction:

The number of older people living with frailty in Swansea Bay is increasing. Currently there is no dedicated rapid access multidisciplinary team (MDT) clinic for older adults living with frailty within Swansea Bay University Health Board (SBUHB). As a response to this, the team at Singleton Hospital (SBUHB) piloted a rapid access MDT clinic.

Method:

The ‘Rapid Access Clinic for the Older Person’ (RACOP) pilot ran for eight weeks across May and June 2022, delivering three clinics per week. Comprehensive Geriatric Assessment was provided via a multidisciplinary team consisting of a Consultant or Specialist Registrar in Geriatric Medicine, Advanced Nurse Practitioner, Pharmacist and Therapy Team.

Results:

41 referrals were screened and 30 patients were booked in to clinic. Of those 30, 25 were assessed. Referrals came from a variety of sources and on average, patients were seen in clinic within 5.9 days of referral. The 25 patients assessed were predominantly female (72% female and 28% male) and the ages of patients ranged from 57 to 99 years old, with the average age being 81 years old. Rockwood Clinical Frailty Scale (CFS) scores showed that 96% of patients assessed had a CFS of ≥4 and 33% had a CFS ≥6. In keeping with this pattern of frailty, all the patients were co-morbid, with 92% having more than five co-morbidities. Patients with a range of diagnoses were assessed and following assessment, only two patients required a follow up appointment. Patient experience data was collected using a validated patient experience form. All patients left positive comments and unanimously said they would recommend the service to family and friends. Staff feedback data was equally as supportive of the service.

Conclusion:

The older adult population of SBUHB would benefit from a service of this type and the patients and staff are supportive of this.

Introduction:

The General Surgery directorate at Cardiff and Vale University Health Board secured funding for the appointment of a Memory Link Worker (MLW) for a 12-month pilot in the emergency stream. The aim of the MLW is to improve patient experience for those living with dementia/ cognitive impairment, or those who experience delirium whilst in hospital. In addition, the MLW role should increase awareness and completion rates of “Read About Me” (RAM).

Method:

The pilot scheme started in February 2022. Eligible patients were identified by ward staff or the Perioperative care of Older People undergoing Surgery (POPS) team and referred in person or via bleep. The MLW reviewed patients, offered activities, contact families / carers and completed the RAM. MLW input continued for the duration of the admission. Objective assessment of the impact of the MLW interventions on patient wellbeing was completed through Dementia Care Mapping (DCM) – an observational tool to improve person-centred care for people living with dementia.

Results:

The MLW has reviewed 52 patients to date, spending an average of 5 hours 51 minutes with each patient during their admission. Three quarters of patients engage in activities offered by the MLW. DCM demonstrated a positive impact on patient well-being, mood and engagement. Very few patients were able to self-entertain in the absence of the MLW and those that did were using tools supplied by the MLW.

Conclusion:

The MLW role has had a positive impact on patient experience as demonstrated by the DCM process. Further analysis of the impact of the role is underway, including feedback questionnaires from staff members and service-users, as well as re-audit of RAM completion rates. We hope this will support a business case to ensure the MLW is a substantive role in general surgery in the future.

Introduction: A summary of the best available evidence in relation to the importance and awareness of hospital associated deconditioning (HAD) and barriers associated with hospital-based deconditioning prevention in order to evaluate the effectiveness and feasibility of deconditioning prevention programmes. Additionally, to gather available evidence focused on the implementation of a national programme. Method: Literature search of Published and unpublished studies and trials were searched using various databases; HDAS (Healthcare Database Advanced Search) databases (OVID platform) Embase, British Nursing Index (BNI) etc. 104 search records were gathered and step by step removal of duplicates and application of inclusion and exclusion criteria was conducted then local studies and trials were prioritized, as the primary objective was to collect evidence for deconditioning prevention programmes, national implementation of a deconditioning prevention programme and evidence for their effectiveness. Results: Two studies focused on the importance of hospital associated deconditioning (HAD), 2 investigated the risk factors of hospital associated deconditioning (HAD): the remaining 10 studies and trials were on deconditioning prevention programmes. Conclusion: This review identified the scarcity of published data on UK based studies and trials on deconditioning prevention programmes and also it would be beneficial to introduce deconditioning prevention in the Trust as mandatory training, because deconditioning prevention in older patients is every staff member’s responsibility. Upon analysis the well-coordinated and funded approach could be the key element in the success and sustainability of the Canadian ‘MOVE ON’ programme in comparison to UK deconditioning prevention programmes. The danger for the UK movement is the lack of allocated funds, which makes intervention more difficult and a struggle to sustain. To remedy this, the cost-effectiveness of reconditioning programmes needs to be strongly emphasized to commissioners. Lack of published evidence of effectiveness and data on positive outcomes would delay implementation of a national programme.