CQ - Patient Safety

Introduction:

Falls account for 17% of emergency department (ED) attendances and cause significant morbidity and mortality in older people. An accurate falls risk assessment can identify those at risk of inpatient falls. At Northumbria Healthcare NHS Foundation Trust, the ‘Avoiding Falls Level of Observation Assessment Tool’ (AFLOAT) was developed to identify patients requiring higher levels of observation to prevent falls (Richardson DA. ClinMed (Lond). 2020; 20(6): 545-550). Whilst AFLOAT was commonly used for inpatients, it was rarely completed in ED. A multi-disciplinary and inter-speciality group was formed from ED and Geriatric Medicine teams aiming to improve falls risk assessment for elderly patients within ED.

Aim:

To improve completion of AFLOAT to >70% for patients >75 years admitted to ED

Method:

Of ED attendees > 75 years from RCEM QIP data, 6 patients were randomly selected daily from December 2023 - January 2024 to assess AFLOAT completion. Those attending during the Holiday period and NEWS scores >6 were excluded. Educational interventions were implemented in January 2024 involving face-to-face teaching for all clinical staff in ED and posters placed in the ED seminar room. Data was re-collected for February 2024 and is ongoing for subsequent months. Results: 19.12% of patients had AFLOAT recorded between December 2023 – January 2024. Following our interventions, in February 2024 AFLOAT completion rates rose to 24.69%.

Conclusions:

Whilst improvement has been seen after interventions, we have not yet achieved our target of 70%, suggested ongoing actions: • Questionnaire amongst ED staff on AFLOAT to promote familiarity and look for reasons for incompletion. • Add an electronic prompt into clerking and falls proformas. • We have asked technicians to remove a comment on AFLOAT implying that it should only be completed by nurses. • Attend Junior Doctor inductions to broadcast completion of AFLOAT. Ongoing PDSA cycles in progress.

Introduction With an increasing ageing population, more people are now living with multiple comorbidities and on polypharmacy. Medicines prescribed appropriately provide huge benefits; but inappropriate prescribing without safe optimisation can cause significant harm.

Method We assessed current practices of reviewing and optimising medications in Elderly Care at Maidstone Hospital. 44 Patients were selected randomly from three elderly care wards. We retrospectively evaluated if medications for these patients were reviewed and optimised using the START-STOPP tool at clerking, post take and Geriatrics review.

Results Of the 44 patients screened, 31(70.4%) patients had all their home medications prescribed at the time of clerking but only 23(52%) had their medications reviewed at the time of clerking, based on clear documentation. 11 patients had some of their medications stopped. 23(52%) had their medications reviewed at the time of post take ward round. 19 of the 23(82.06%) had some of their medications stopped. 25(56%) had their medications reviewed at the time of Geriatric review. 15 patients(60%) had their medications stopped. Most medication reviews with clear documentation took place at the time of Geriatrics' review (56%). Least medications were reviewed and stopped at the time of clerking. Most number of patients had their medications stopped at the time of PTWR and geriatrics' review.

Conclusion It is important for admitting teams to ensure all home medications are reviewed and correctly prescribed within 24 hours of acute admission, in keeping with NICE guidelines. This ensures patients do not miss any crucial drugs and also unnecessary medications are stopped, minimising drug related safety-incidents. Least number of drugs were stopped by clerking doctors, which suggests lack of adequate training and low confidence in stopping medications. As such teaching and awareness of junior doctors re: polypharmacy and use of STOPP/START tool is crucial. Electronic clerking proforma prompts will also prove helpful.

Introduction -

The British Thoracic Society Guidelines 2017 recommends oxygen delivery to achieve target oxygen saturation range between 94% and 98% of the majority of medically unwell adult patients, and 88% to 92% in patients at risk of hypercapnic respiratory failure. Oxygen is a drug which should be prescribed for patient’s just like any other medication and is often over-looked. For some older people oxygen treatment can impair mobility, increase deconditioning and the risk of falls. We conducted a re-audit and PDSA cycle expanding from one ward (Eashing) to all three geriatrics wards over a 9-week period, to assess and improve compliance and patient safety.

Method -

A retrospective approach gathered data on a weekly basis, using all listed in-patient electronic medical records. Patient’s identified as having an oxygen requirement after first contact with a consultant when new to the wards, were reviewed as to whether oxygen was prescribed or not. A 5-week baseline audit and then one PDSA cycle over 4 weeks was implemented; with baseline results disseminated to the ward MDT’s with posters placed in each ward, 2 weeks later ward consultants and junior doctors were e-mailed.

Results -

5-week baseline audit; total patient population: 47. Eashing 11/16 patients = 68%. Elstead 1/14 patients = 7%. Hindhead 0/17 patients = 0%. 4 weeks following PDSA cycle completion; total patient population: 25. Eashing 8/9 = 88%. Hindhead 7/11 = 64%. Elstead 2/4 = 50%.

Conclusion -

Improvement in oxygen prescription compliance was noted across all wards, a clear upward trajectory in the results. On Eashing, teamwork and the involvement of nurses and their help was key to the improvement and highest compliance rate. The main barrier to sustainability is the rotation of new junior doctors, mitigated for through MDT dissemination & posters as well as consultant awareness.

The World Health Organisation lists antibiotic resistance as one of the biggest threats to global health [1]. We contribute to this as clinicians, through errors such as delayed review of prescriptions or prescribing against local trust guidelines. We have carried out a quality improvement project to improve antibiotic prescriptions on a geriatric ward at Croydon University Hospital. We carried out a fortnightly cross-sectional analysis of the antibiotic prescriptions on a geriatric ward. This included looking at the antibiotic prescribed, indication, duration, route of administration and presence of a review date. These were then compared to trust guidelines. After the first 8-weeks, we delivered a departmental teaching session on antibiotic prescriptions. We then re-audited the prescriptions. Following this, we sent out weekly email reminders on locating trust guidelines and information on prescriptions. We then re-audited following this. Finally, we created an e-learning resource to deliver to the ward on antibiotic prescriptions. We are planning to deliver this to the ward and re-audit afterwards. Initially, up to 90.0% of prescriptions differed from trust guidelines. Common reasons for differences when compared included incorrect drug prescribed, incorrect frequency of dosing, or non-specific indications leading to difficulty comparing. Following all interventions, approximately 32% of prescriptions differed from trust guidelines. This showed sustained improvement across 2 complete PDSA cycles (plan,do,study,act). A 3rd PDSA cycle is ongoing at present and preliminary data has shown approximately 28% of prescriptions differed from trust guidelines. This quality improvement project has successfully contributed to a reduction in prescription errors and safe prescribing. We will continue to provide information to our colleagues on antibiotic stewardship, to further encourage safe prescribing. [1]. Antibiotic resistance (2020) World Health Organization. Available at: https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance (Accessed: May 2023).

Introduction

In 2022, 293 hip fractures had been admitted to the Bristol Royal Infirmary. As recommended by National Osteoporosis Guideline Group ( NOGG ) intravenous zoledronate is the first line treatment option following a hip fracture.

Aims

We wanted to improve bone health summaries on discharge summaries for the benefit of the General practitioner ( GP ), Fracture liaison service and patient.

Results

We used our local National Hip Fracture database to identify the patients who had had a fractured hip in September 2023. We then introduced our changes as part of the PDSA cycle. The change was copying and pasting a blank bone health paragraph into every discharge summary on day 1 of the patient's admission to make it easier for the Trauma and Orthopaedic (T&O) junior doctor completing the discharge summary pre discharge. We then used an excel spreadsheet to collect results in September and October 2023 and analyse them and display them using pie charts. In September , 28.3% of discharge summaries did not have a bone health plan, compared to 25% in October. Not mentioning of Vitamin D levels in discharge summaries has increased from 57.1% to 59.4%. Mentioning of administration of inpatient zoledronic acid post fracture decreased from 32.1% to 25%.

Conclusion

Despite the intervention,The bone health plans are poorly communicated to the GP and the Fracture Liaison service, which leads to delay in administering bone health medication in a timely manner to prevent a second fracture.

Next step

Teaching Session with the T&O juniors to find out if they think it’s a good idea and discuss why they have not found the current standardised paragraph helpful. Then we can work together to make a further change (s) and start another PDSA cycle.

References

National Osteoporosis Guideline Group.UK ( NOGG ),2021

Introduction

Information-sharing between primary and secondary care is vital for patient safety and reducing duplication. The Electronic Discharge Summary (EDS) enables this but is often incomplete due to time pressures and poor team continuity. Information from the Comprehensive Geriatric Assessment (CGA) by the Perioperative care of Older People undergoing Surgery (POPS) team is often omitted, leading to queries from primary care colleagues and duplication of work on readmission to hospital.

Methods

Eight core CGA components were determined for inclusion in the EDS. Twenty EDS were reviewed to for each PDSA cycle to assess compliance. Various strategies were trialled to increase compliance including junior doctor education (attendance at induction plus separate teaching), a checklist poster, the POPS team directly entering information into the EDS and a separate CGA summary.

Results

Baseline data demonstrated poor compliance with core CGA components (mean 25%, range 0-62.5%). PDSA 1 demonstrated improvement after junior doctor education and introduction of a checklist poster (mean 35%, range 12.5-87.5%). Mean compliance increased to 53% during PDSA 2 with the POPS team directly entering information into the EDS, but with continued wide variation (range 12.5 – 100%). The introduction of a POPS CGA summary to complement the EDS in PDSA 3 increased compliance with reduced variation in practice (mean 99%, range 87.5-100%).

Conclusions

Sharing information gleaned from a CGA was marginally improved with education, but is challenging due to the rotational nature of staff completing the EDS. The improvement seen with the POPS team entering EDS information was limited by the lack of 7-day working and the ‘locking’ of the completed EDS by the parent team. A separate CGA summary markedly improves information-sharing, with reduced variation in practice. This has benefitted primary and secondary care colleagues, as well as the POPS team when patients are readmitted or attend clinic.

Introduction

Effective bowel care is a key part of patient care which involves the accurate documentation of bowel movements. Older patients are at higher risk of delirium and increased length of stay if constipation and diarrhoea are not recognised. We aimed to identify the quality of bowel chart documentation comparing the use of paper and electronic bowel charts.

Methods

Data was collected on whether bowel charts were filled in at two timepoints over a two-day period. The first cycle in September 2020 using paper bowel charts and the second cycle in June 2023 using electronic bowel charts. All inpatients, on the geriatric wards were included unless they were on end-of-life care or had moved ward on the day of data collection.

The primary outcome was whether the bowel charts for both days were filled in fully. Secondary outcomes were whether the bowel charts were ‘easy to find’ and whether there was reference in the notes to the bowel chart. Data was analysed using a Mann-Whitney test.

Results

In the first cycle data was analysed on 129 inpatients, 4 were excluded and in the second cycle data was assessed on 128 inpatients, 16 were excluded.

Conclusion This quality improvement project shows how the introduction of electronic bowel charts has had a significant improvement in the charts being filled out and easy to find. 

Introduction: According to the latest NELA report(1), frailty doubles the risk of mortality in patients >65 and above, but review by a geriatrician can significantly reduce this risk. To identify patients at risk, the report recommended that a formal frailty assessment for all patients>65 should be performed. The aim of this audit was to check compliance with this recommendation.

Methods: Data were collected retrospectively from a prospectively maintained electronic hospital records. Patients > 65 years admitted acutely under general surgery were identified from handover lists spanning a period of two weeks. The admission documents were reviewed to check for a formal assessment of clinical frailty score (CFS) had been completed. Following initial results, posters were put up in the SAU doctors office and all clerking doctors made aware via e-mails, WhatsApp groups and teaching to complete a CFS for patients >65 years. Results: In the first cycle, 50 patients were identified and compliance rate was 18%. Following intervention, 51 patients were identified in the subsequent cycle with a compliance rate of 47%. After a second intervention, 99 patients were identified with a compliance rate of 61%.

Discussion: The NELA report highlighted only 23% of patients had a CFS documented and this was similar to the results of the initial audit. The main reason was lack of awareness, which was addressed by creating an awareness among the colleagues via poster, group chats and emails. This brought compliance up to 47% Another reason was doctors being unable to locate the CFS on the electronic clerking document. A second round of intervention by poster, group chat, email communication and teaching achieved a 61% completion rate. The recommendation is to continue to improve the documentation of CFS further and utilize this to get input from geriatricians.

Introduction

There are around 250,000 inpatient falls in English hospitals each year. Inpatient falls are associated with poor outcomes. Evidence suggests multifactorial assessment and intervention is the most effective way to prevent inpatient falls. There are National Institute of Health and Care Excellence (NICE) quality standards for safe post fall management. National audit supports improvement in the quality and safety of clinical care.

Methods

The National Audit of Inpatient Falls (NAIF) began collecting continuous data from all femoral fractures (as identified on the National Hip Fracture Database) in England and Wales from 2019. Prospective documentation review collects data on multifactorial falls risk assessment (MFRA) prior to the femoral fracture as well as immediate post fall management and presents performance indicators related to NICE guidelines/quality standards.

Results

There are around 2000 inpatient femoral fractures each year. Those with an inpatient fracture have double the 30-day mortality of those who fracture elsewhere, highlighting the vulnerability of this group of patients. There has been improvement in most aspects of MFRA and the proportion of patients checked for injury before moving from the floor has increased from 69 to 77%, use of flat lifting equipment from 22 to 29% and medical assessment within 30mins of the fall from 52 to 60%.   

Discussion

There have been steady improvements in guideline compliant inpatient fall-prevention and post-fall management, but there is more to do. The programme also produces improvement resources and activities and will be expanding the range injuries covered in the next 2 years.

Introduction

Upper limb recovery after stroke depends on participating in an individualised task-specific exercise programme. However, older adults with stroke find it challenging to maintain an optimal level of physical activity due to personal and environmental factors. The aim of this study was to explore the perceptions of patients and stroke therapists on home-based resistance exercises for upper limbs.

Methods

A qualitative study of semi-structured virtual and in-person interviews was conducted between January and March 2023 in England. Participants were 11 older adults (>65 years) with chronic stroke (>1 year after a stroke and moderate to severe disabilities) and rehabilitation therapists (n=20). The group were asked about perceived personal and environmental barriers and facilitators as well as expectations around resistance exercises in relation to their neurorehabilitation programmes. Interview sessions were audio recorded for transcription and thematic data analysis. The study was approved by the ethics committee at Sheffield Hallam University.

Results

Both groups mentioned that the main barrier to doing upper-limbs exercises is weaknesses in the paretic arm affecting their grip that consequently impacts on their adherence to a home exercise programme and motivation. Patients also reported safety concerns such as dropping equipment and being dependent on a carer to undertake regular exercise. Stroke suvivors preferred a program that activates the paretic arm and is relevant to their daily functional activities. They asked for simple exercise instructions and demonstrations through visual aids and video materials. Patients added that they need regular feedback for adjusting their exercise dose, monitoring progress over time, and ongoing encouragement.

Conclusions

Our study showed that designing home-based resistance exercises for upper limb for older adults stroke survivors should be individualised, functionally orientated, and motivational.