CQ - Improved Access to Service

Background
Current practice for acute delirium presentation is hospital admission whilst the delirium resolves, often including multiple transfers with poor outcomes. This project challenges this practice and allows people to recover at home with a maximum of 6 calls a day and night with carers trained in delirium.

Results
From a previous audit of Pathway 2 beds patients with delirium had poor outcomes, high levels of placement in permanent care and long lengths of stay (21 days).

There have been 192 episodes of care through the Delirium Pathway.80% were from hospital wards and 20% stepped up from community settings.

In 2023, 42% had no ongoing social care support needs and 21% had only the requirement of ongoing domiciliary care needs at home. 2.6% entered long term care with the re-admission rate remaining within the local rate for this cohort of 20-30%. There has been low demand for night care. The average LoS is 15 days.

Delirium symptoms significantly improved at discharge and stayed improved; pre-discharge the median 4AT score was 7, at first pathway assessment (generally within 24 hours of arrival home), the median 4AT score was 2 and at exit of pathway the median 4AT score was 1.

Patients and carers reported that the discharge home felt safe and that home was the best place for recovery: 89% of patients and 76% of carers felt it was safe to return home; 94% of patients; and 93% of carers felt that home was the best place for recovery.

Conclusion
This pathway has demonstrated that discharging patients with an acute delirium with supportive home care is safe, effective, and reduces admissions to long term care

Introduction

With the emergence of disease modifying treatments for Alzheimer’s disease (AD), there is an increasing emphasis on the earlier detection and diagnosis of AD. Cerebrospinal fluid (CSF) sampled using lumbar puncture (LP) can be used to establish a biological diagnosis of AD. One potential obstacle to the widespread adoption of CSF biomarkers for AD diagnosis has been a perceived association with poor patient tolerability and safety of LP. LPs have been undertaken within our Geriatrician-Led Memory Service since May 2022. Patients are provided with a written information sheet prior to LP.

Method

A survey was developed in-house by the clinical team. A service evaluation initiative was registered within the local trust. All patients attending for LP since May 2022 were posted a feedback form with an enclosed pen and stamped addressed return envelope on 5th August 2024. Questions included: what the patient’s understanding was of why they were having a LP, whether the written information sheet provided sufficient information, their overall experience of the LP and whether there were any concerns about the procedure.

Results

Of the 36 feedback forms posted, 17 (47%) were returned. Of the 17 responses received, 12/17 (71%) patients strongly agreed and 4 (24%) patients agreed that they understood why they were having a LP, what a LP involved before attending and that the leaflet provided sufficient information about a LP procedure. All 17 patients agreed that they were satisfied with their overall experience of the LP procedure. 5/17 (29%) patients stated they had concerns during or after the procedure; these included length of time taken for results to become available.

Conclusion

This survey of patients attending a Geriatrician-Led Memory Service for LP found obtaining CSF biomarkers for AD to be a well-tolerated procedure with high overall patient satisfaction.  

Introduction

The Royal College of Physicians (RCP) introduced guidance on implementing frailty assessment and management in oncology services in November 2023. Frailty-informed care has been demonstrated to improve outcomes. The RCP suggests that where the management of frailty is beyond the skillset of the oncology team, links should be built with local geriatric teams to ensure holistic care, responding to individual needs.

Method

We set up a referral pathway within an existing geriatric clinic at a district general hospital, facilitating referrals initially from oncology colleagues, then expanding to haematology. This was complemented by drop-in sessions and multi-disciplinary teaching sessions on frailty and comprehensive geriatric assessment.

Results

There were 23 referrals between January and November 2024. The median frailty score was 5. Cancer sites included rectal, urological, upper GI, lung and haematological malignancies. The majority of referrals were for polypharmacy (6), pre-treatment optimisation (6) and poor mobility (6). Other categories included falls and advance care planning. Patients waited between 2 and 21 days for an appointment. Outcomes for patients seen included rationalising medications (8); onward specialty team referral and investigations (7); multidisciplinary involvement (4) and advance care planning (2). Through our interventions, assessment of frailty score improved from 0 to 96% of patients in this sample.

Conclusion and next steps

We have demonstrated the feasibility of integrating an onco-geriatrics pathway into an existing geriatrics service and nurturing links between departments through regular teaching sessions. As well as improving access to services for older adults, this provides training opportunities to resident doctors. Patient survey data is currently being collected to look at the impact of this service on patient experience. Whilst outside the scope of the initial project, future work could look into whether the positive impact of this service translates into a reduction in re-admissions in this cohort of patients.

1.           Introduction

At Wrightington, Wigan and Leigh 412 patients were admitted with hip fracture diagnoses in 2024.  As part of the orthogeriatric review, bone health medications zoledronic acid and denosumab were utilised in this cohort of patients, where appropriate, to address the significant risk of “imminent fracture” in line with NOGG guidelines. The aim was to review January to June of 2024; 118 patients were evaluated, reviewing delays in initiation of these treatments to improve services and patient care.

2.           Method

Utilising hospital electronic records, a sample of patients were selected from those admitted in 2024 (118 patients). These were split into treatment choices zoledronic acid (59 patients) and denosumab (59 patients) to better evaluate the pathways for each treatment. An intervention to consent and initiate treatments before discharge in patients presenting with a hip fracture was implemented at WWL in September 2023. The results reviewed the number of patients receiving treatments before discharge, the date range variation between first doses and why these were so varied.

3.           Results

The average length of time for first dose denosumab was 62 days, improved greatly since 2022 (187 days) and 2023 (76 days). The average length of time for first dose zoledronate was 72 days with no comparative data. Further analysis shows how zoledronate delays in 91% of patients was due to the practice of not administering bisphosphonate medications within 14 days of surgery, a practice that has now changed. Furthermore, 64% of denosumab patients and 75% of zoledronate patients were delayed due to replacement of vitamin D.

4.           Conclusion(s).

Implementation of inpatient consent has been shown to expediate first dose denosumab greatly. Analysis of data will be required to review the first dose administration of zoledronate; stopping limitations such an administering within the 14 days of surgery should reduce delays further.

Introduction 

The Commissioning for Quality and Innovation (CQUIN) framework sets a 10% minimum and an ideal goal of 30% of acutely presenting patients over the age of 65 to receive frailty assessment scores. Early recognition of frailty helps mitigate risks such as deconditioning. This project aims to assess and improve the adoption of this standard in medical emergency admissions of a Birmingham district general hospital by working with medical admissions teams and frailty services and observing for associated outcome measures.

 Methodology

 PDSA methodology was used. Data was retrospectively collected for patients aged 65 and above from the electronic patient records (EPR) over a week’s interval from the acute medical take. Collected data included prevalence of CFS scoring and social history, escalation discussions and mortality. Interventions were delivered via an educational presentation to resident doctors and displayed posters in key areas. The data was examined for improvements in CFS prevalence and its relationship with onwards referral, escalation discussions or mortality. Results Pre-intervention only 3.31% (8/242 patients) had a recorded CFS score . . Post-intervention, 19.10% (34/178) patients had a CFS score documented. Post-intervention, 82.35% of those with CFS scores were referred to the frailty therapy service, as opposed to 17.36% of those without CFS scoring. Escalation discussions were had with 41.17% of those with CFS scoring and 29.17% of patients without. Mortality was 5.88% in the CFS scored patients and 9.72% in the patients with no CFS score. 

Conclusion

 After focused interventions, the CFS prevalence was above the 10% minimum requirement and closer to the 30% goal set by the CQUIN 05. Patients with a CFS score saw higher rates of onwards referrals to older person services, and higher rates of escalation discussions . In forwards application, CFS could be discussed in induction, incorporated into IT clerking systems
 

Introduction

Fragility fractures are a significant cause of morbidity and mortality in the UK. An estimated 549000 fragility fractures occur each year, with a significant financial and social cost. By identifying and treating those at risk we can reduce the incidence of fragility fractures. We wished to assess how we could optimise management of bone health in those presenting to our acute frailty unit(AFU). 

Method

We conducted a retrospective review of patients admitted to AFU with falls on a background of frailty. 2 PDSA (plan, do, study and act) cycles were undertaken in 2023 and 2024 respectively. We audited if patients had a full assessment of bone health (calcium, Vitamin D levels and FRAX score) and if they had been started on appropriate treatment. Interventions included multiple educational sessions for members of the elderly medicine team, updated guidelines for primary and secondary prevention and concise poster guidelines visible on all elderly care wards. 

Results 

Over two cycles, we noted an improvement in bone health assessments amongst those admitted. By the end of our cycles, 48% had appropriate bone health bloods compared to 13% prior and 33% had a FRAX score calculated compared to 7% before. 32% of the patients had a clearly defined treatment plan for bone health compared to 0% at the start of the cycle. 

Conclusions 

1. Education proved a moderately successful tool for increasing the awareness of bone health in frail patients admitted to AFU and also in increasing appropriate assessment and management of these patients. 2. Despite this, the majority of patient’s did not receive an assessment. Possible factors limiting this included; time, clinical acuity and uncertainty about best management option. 3. This QIP has demonstrated the need for the development of a fracture liaison service to provide robust assessment and management in the frail population.

Introduction: Frailty is a clinically recognized condition characterized by increased vulnerability due to age-related decline across various physiological systems, leading to reduced ability to cope with daily and acute stressors . Managing frailty requires a person-centred approach, involving patients, families, and caregivers, and utilizing evidence-based practices such as Comprehensive Geriatric Assessment (CGA), delivered by specialist multidisciplinary (MDT) teams. Research indicates that older individuals receiving CGA are more likely to be alive and living independently at home six months after an acute illness. To support the development of Older People’s Services, a review of the service model was conducted to deliver a rapid access service for patients referred by general practitioners (GPs). This service aims to avoid emergency department (ED) visits while providing necessary CGA assessments. Method: The initiative involved creating a direct referral option within the GP’s electronic referral system (Clinical Commissioning Group), developing a standard operating procedure for the triage process, establishing an education process for staff to clarify roles and responsibilities including data collection, and scheduling MDT members for triage support. Results: Following the implementation of the agreed procedures, there was a notable improvement in scheduling urgent GP referrals within three days. A daily referral system with live triaging was established, along with daily post-clinic MDT meetings. The backlog of urgent GP referrals was cleared. This successful system was replicated using Plan-Do-Study-Act (PDSA) cycles to integrate ED referrals. Conclusion: Collaborating with a team whose values aligned with Health and Social Care (HSC) principles—working together, striving for excellence, openness, honesty, and compassion—was a rewarding experience. The project provided valuable learning opportunities in team-building and service development. The success of the GP referral system was also leveraged to expand the service to other areas, such as ED referrals, demonstrating effective duplication of successful strategies.

Background: The NHS Long Term plan calls for change to deliver proactive community frailty care1. Proactive frailty case-finding outside traditional healthcare settings should be explored2. 

Aims: To pilot test proactive frailty screening at a community event. Methods: GSTT Musculoskeletal Physiotherapy department hosted a community day in a deprived area of Lambeth, London. Waiting list residents were invited for a café-style assessment. Stalls were available to meet wider needs including finances, wellbeing, Ageing Well and others. Ageing Well (Consultant Geriatrician & Geriatrics trainee) completed frailty screening using a 1-page screening tool with follow on assessment/interventions. Accessibility evaluated by characteristics of attendees. Feasibility and acceptability evaluated by participation and assessment completion. Appropriateness by prevalence of frailty needs, number of interventions arranged. 

Results: 137 residents accepted, 26 (19%) were 65+ years old. 14 residents were reviewed by Ageing Well. Mean age 67 years (57-80), mean 4 comorbidities, 72% from ethnic minority groups, mean Clinical Frailty Scale (CFS) 4 (range 2-5). 43% were digitally excluded (unable to use internet or phone). All 14 residents participated freely in an open setting suggesting acceptability including sensitive topics e.g. continence/mental health. The Frailty screening tool identified significant needs: pain (93%), fatigue (64%), falls (50%), mental health concerns (64%), medication management (50%), bladder concerns (50%), difficulties with activities of daily living (57%), financial concerns (43%). 43% attended ED in the last year. Only 1 was known to social services but 43% had informal help from friends/family. Personalised care plans included bone health interventions, medication changes, continence management, strength/balance exercises programme access, equipment provision, social services access, self-management advice/information . 

Conclusions: Ageing Well screening & assessments appeared feasible, acceptable, accessible and appropriate to managing frailty needs proactively in ambulant vulnerable-mildly frail residents. This proactive outreach approach should be explored at alternative outreach events.

Introduction

Frailty in older adults increases risk of hospital admission, prolonged stay, and poorer outcomes. The NHS Long-Term Plan emphasises early identification, admission avoidance, and shifting care into the community to reduce system pressures and improve patient outcomes. Bromley has one of the largest and fastest-growing older populations in South East London. The One Bromley Hospital at Home (H@H) service is a multidisciplinary, person-centred service, integrating step-up and step-down pathways. Dedicated frailty and palliative care arms ensure high-risk patients receive coordinated, specialist-led care, embedding multidisciplinary meetings with geriatricians and palliative care teams. 

Methods 

A one-year retrospective evaluation (April 2023–2024) assessed service utilisation, clinical outcomes, technology integration and patient satisfaction for frailty/palliative arms of this service. 

Results

• Service growth: H@H referrals tripled from 32 to 107 (April 2023 vs 2024). Over the year, 800 patients received care with 17,400 patient contacts, 53% face-to-face. • Frailty and palliative care expansion: frailty referrals increased by 200% contributing 45% of H@H referrals, palliative referrals accounted for 15%, supporting complex end-of-life care at home. • Patient Profile: average age 84.1 years; 55.1% male • Pathway Impact: step-down referrals (62%) facilitated early hospital discharge, whilst step-up admissions (38%), prevented acute hospitalisation. Frailty vs Palliative LoS were 8 vs 4.5 days respectively. • Digital Integration: 25-30% of patients benefited from remote monitoring, reducing hospital escalation and improving clinical oversight. • Readmission rates averaged 12.5%, reflecting the complexity of the caseload. • Patient satisfaction remained consistently >90%, highlighting positive patient experience and acceptability of home-based frailty care. 

Conclusion 

This H@H model aligns with national UEC transformation priorities by: reducing hospital dependency through proactive frailty management, integrating frailty/palliative pathways within the virtual ward, enhancing health equity and access to out-of-hospital care. Future research to evaluate long-term sustainability and cost-effectiveness is key before wider adoption across Integrated Care Systems.

The Frailty Hotline is a follow-up service designed to provide ongoing care and support to patients discharged from the frailty service. Patients who have previously been under the care of the frailty team are given a dedicated phone number that allows them to escalate non-urgent concerns regarding their health. This service ensures that patients continue to receive appropriate care and guidance while remaining in their home environment, reducing the need for unnecessary hospital visits.

This quality improvement project sought to evaluate the effectiveness of the Frailty Hotline in reducing avoidable ED visits and improving patient care. The PDSA cycle  was conducted over a 15-day period. During this time, the frailty practitioners at the Royal Preston Hospital responded to a total of 47 phone calls. Details of the calls were recorded using a pro forma to ensure accurate information capture.

The majority of identified concerns centered around queries regarding patient management and issues related to patient symptoms and health. When a problem or concern was identified, actions were typically taken to address it. The majority of the actions involved providing advice to patients and seeking clinical advice from senior practitioners. A significant number of patients were also escalated to the Virtual Frailty Ward.

Out of the 47 phone calls received, 16 (34%) addressed patients' symptoms that could have potentially resulted in Emergency Department (ED) presentations. Of these 16 patients, 9 (19%) were escalated to the Virtual Frailty Ward, potentially preventing hospital admissions. One patient called 999 due to extreme pain and may have presented to the ED. There was no geriatrician available at the time to advise.

This highlights the critical role of the Frailty Hotline service in reducing unnecessary ED visits and hospital admissions. The Frailty Hotline service also played a vital role in improving patient outcomes by addressing a range of queries related to medications, symptoms, and pending investigations, which could have otherwise resulted in unnecessary phone calls to GPs and other services.