CQ - Improved Access to Service

Background 

Delirium and acute functional decline are common in hospitalized older people (HOP), yet data remain scarce. A shortage of geriatricians and geriatric-trained doctors in our healthcare system contributes to poor clinical outcomes, including increased readmissions, morbidity, and mortality. This pilot study aims to assess the clinical burden of HOP—including rates of readmission, delirium, and acute functional decline—before implementing frailty care bundles in general medical wards. 

Methodology 

This prospective cross-sectional study recruited HOP (≥65 years) admitted to general medical wards from 1–31 March 2024. Data collected included demographics, prior-year readmissions, ADL and mobility status (1 month pre-admission vs. discharge), presence of delirium (via symptoms or Confusion Assessment Method), and length of stay. Acute functional decline was defined as deterioration in at least one ADL or mobility domain. Patients transferred to other specialties or district hospitals were excluded. 

Results 

Of 107 HOP (33.7% of total admissions), 103 were analyzed. Median age was 73; 80.6% were 65–80 years, and 59.2% were male. At baseline, 76.7% were CFS ≤5, while 23.3% were moderately/severely frail (CFS 6–7). Prior to admission, 48.5% walked unaided, while 51.5% required assistance. Readmission history was noted in 46.6%. Mean length of stay was 6.5 days. Acute mobility decline occurred in 37.9%, functional decline in 35%, and delirium in 17.5%. 

Conclusion 

This study highlights a substantial clinical burden among hospitalized HOP. A standardized frailty care bundle has been developed to aid non-geriatric-trained healthcare personnel in early detection and management of frailty-related issues, aiming to improve patient outcomes.

Introduction: Frailty is a growing concern, particularly for older adults attending Emergency Departments (EDs). Frailty accounts for 5-10% of all ED visits and up to 30% of acute admissions1. The NHS mandates that hospitals with Type 1 EDs provide a minimum of 70 hours of Acute Frailty Services per week to address this challenge1. At Salford Royal Foundation Trust (SRFT), a Frailty Same Day Emergency Care (SDEC) service was introduced to deliver rapid assessment and care for frail older adults, aiming to reduce hospital admissions and improve patient outcomes2. This service operates five days per week and is staffed by a multidisciplinary team2. Methods: A mixed-methods approach was used to evaluate the Frailty SDEC service3. Data was collected through paper surveys distributed to patients aged 65 years or older with a Clinical Frailty Score (CFS) >5 and their relatives or carers during their admission to the SDEC service24. The survey included both closed-ended and open-ended questions4. Quantitative data was analyzed using descriptive statistics and qualitative data was analyzed using thematic analysis5. Results: A total of 32 responses were collected over a two-month period in 20244. The results showed high levels of patient and family satisfaction (97%) with the Frailty SDEC service35. Participants particularly valued the compassionate and personalized care, clear and professional communication, and the efficient and timely service delivery67. Areas for improvement included upgrading the physical environment and providing clearer communication about waiting times and procedures89. Conclusion: The Frailty SDEC service at SRFT demonstrates high levels of patient satisfaction and effectiveness in delivering care for frail older adults10. This evaluation provides valuable insights for enhancing patient-centered care and highlights the importance of further research to explore long-term outcomes and compare different models of SDEC services for older adults11

Introduction Early access to specialist care is recognised to be beneficial for older adults living with frailty. Decision-making around assessing function and mobility to facilitate safe discharge can be challenging for staff in an Emergency Department environment. This can result in patients being admitted to await specialist review. The aim of this test of change was to explore the role and contribution of a Specialist Frailty Allied Health Professional (AHP) within the ED and to evaluate the impact on the care of patients living with frailty.

Methods For a 12-month period, the ED has had a dedicated frailty AHP to support staff in assessment. The role was adapted based on the needs of the clinical service. The impact of this intervention was evaluated using system-level performance data including frailty ascertainment; length of stay and discharge from ED. Staff feedback and patient journeys were collected to supplement quantitative insights. 

Results There has been a 257% increase in patients being assessed by an AHP in ED (implementing early Comprehensive Geriatric Assessment (CGA)) and a 247% increase in number of patients discharged directly from the ED. In the first five months, there was a significant increase in referrals to appropriate community services, to support patients after discharge home, equivalent to 84-196 bed days. For those who are admitted, their CGA has already commenced and goals established. Staff feedback has shown an increase in confidence of supporting these patients, and greater awareness of both frailty and the services available to support patients after discharge from ED, rather than defaulting to admission. 

Conclusions Having timely access to a dedicated frailty AHP is critical in effective decision making and improving patient outcomes. The Frailty AHP is a well-integrated member of the ED team and wider backdoor services. This has benefitted patients who are admitted and discharged

Introduction: Fracture liaison services (FLS) aim to prevent secondary fractures by ensuring high-quality care to all patients with fragility fractures above 50 years. The standard recommendation by FLS Database (FLS-DB) is to identify 80% of the expected fragility fractures, commencing treatment for 50% and monitoring 80% at 16 weeks and 52 weeks.

Methods: FLS team noted that only 18.4% (n=92) patients were followed at one-year of the total 875 patients identified in the year 2021 (National benchmark=22.3%). Whilst FLS team identified 42.6% (n=1649) patients in the year 2022, an 88% increase as compared to the year 2021. But there was reduction in the one-year follow-up from 18.4% to 13.8% (n=149) in 2022. Quality improvement methodology based on the model of improvement; Plan-Do-Study-Act cycles, was used. Process mapping for the existing FLS showed that follow-up was only ad-hoc and not formalised. Our objective was to improve follow-up at one-year.

Results: Process mapping supported the development of a separate clinic code for annual review of patients, led by a geriatrics specialty trainee and supported by the FLS Clinical Lead. The patient lists were drawn from the FLS-DB and new patients booked for one-year follow-up clinic. FLS identified more fragility fracture patients (n=2181, 61.4%) in 2023, a further increase of 32.2% as compared to previous year. Clinical leadership and dedicated one-year follow-up clinic supported improved performance (21.4%, n=310) in the year 2023, which is comparable to the national benchmark (22.2%).

Conclusion: Several challenges were identified including lack of accurate telephone numbers for many patients; patients are transferred to primary care at one-year but there but the is osteoporosis knowledge gap in the community and need for dedicated time for follow-up clinic. This quality initiative has streamlined our follow-up clinics but need dedicated time to meet the service demand and increased capacity.

Background: Patients triaged as routine, discharged home from Intermediate Care Units (ICUs) in areas of West Sussex wait  approximately 4 weeks or more until rehabilitation continues by the Community Therapy Team (CTT).

Introduction NHS England (2023a) and NHS England (2023b) call for minimal delays, effective coordination processes and sharing of information for timely rehabilitation in intermediate care settings. Local patient feedback indicated poor patient satisfaction and increased clinicians anxiety regarding risk of deterioration due to long waits (Lewis A., 2018).

Aim To improve average wait times for routine ICU patients’ discharge, for ongoing community therapy input, to within 1 week by July 2024, while maintaining patient safety and improving patient satisfaction.

Methodology: Quality improvement methodology, using stakeholder engagement was used to determine the cause for long wait times for home therapy. PDSA cycles were engaged to determine if improvements could be made without a loss of quality of care, or impacting patient safety, while improving patient experience. These involved formal communication channels between teams and using a therapy assistant for an initial home assessment where assessments had already been undertaken by registered therapists on the ICUs. Patient satisfaction surveys were undertaken to understand the experience of transition home.

Results: Baseline data indicated that waiting time for home therapy varied between 18 - 59 days, from discharge. After the initial PDSA cycle, waiting time reduced to between 4 - 10 days, and after the second cycle waits reduced further to between 3 - 7 days. Patients’ satisfaction improved significantly with shorter waiting times for therapy once home.

Conclusion: Therapy assistant initial visits at home reduced waiting times to within a week, and patients’ satisfaction improved with shorter waiting times. Patient safety was not compromised as there were clear protocols for appropriate escalations for unregistered staff.

Introduction

Vertebral fragility fractures (VFFs) are the most prevalent form of osteoporotic fracture, with an incidence of >20% in women >70 years old. While often clinically silent in isolation, VFFs are associated with future osteoporotic fractures, decreased quality of life and an 8-fold increase in age-adjusted mortality.

Radiologists may facilitate early diagnosis of VFFs, allowing for more cost-effective intervention with greater patient outcomes. However, a national audit in 2019 demonstrated widespread failings in the radiological recognition and reporting of VFFs, according to criteria outlined by the Royal Osteoporosis Society. Crucially, only 2% of reports in patients with moderate-severe VFFs recommended referral to Fracture Liaison Services (FLS), compared to the national target of 100%.

Here, we evaluate local VFF recognition and reporting performance, relative to the Royal College of Radiologists (RCR) targets.

Methods:

Single-centre retrospective analysis of all CT thorax, abdomen and pelvis scans in >50-year-olds. Two cycles were completed, with implementation of educational posters and a quick-code reporting alert between cycles. The proportion of reports meeting best practice criteria were measured.

The criteria included: assessment of bony integrity (target 100%), correct identification of moderate-severe VFFs (target 90%), use of correct terminology in reports (target 100%), referral of moderate-severe VFFs to the FLS (target 100%).

Results:

Bony integrity was assessed in 100% in both cycles. Identification of moderate-severe VFFs improved from 37% to 64% between cycles. Correct terminology was used in 63% and 56% of reports in the first and second cycles respectively. 0% of patients were recommended for FLS referral in both cycles.

Conclusion:

This audit demonstrates local shortcomings in VFF recognition and reporting. While there was an improvement in identification of VFFs between cycles, RCR targets were still not met post-intervention. This reflects a nation-wide issue in the under-diagnosis.

Telemedicine uses communications technology for remote healthcare. Unreadiness includes difficulties with hearing, speaking, cognitive issues, vision problems, lack of internet-enabled devices, or no recent use of digital communication. Telehealth can enhance access and convenience, especially for rural patients, but faces challenges such as technology issues and impacts on patient-provider relationships, examination quality, care quality, and patient satisfaction. The COVID-19 pandemic has accelerated telemedicine adoption to protect medical personnel and patients, with significant promotion of video visits for home-based care.

This study aims to evaluate telemedicine unreadiness in an older, frail population at a geriatric clinic. Patients were contacted from February 1st to March 14th, 2021, during Ireland's COVID-19 "third wave," with up to three contact attempts made. Statistical analysis was conducted using STATA 14. 84 patients attended the Geriatric clinic, with 33 excluded for various reasons, leaving 51 participants (67%) who completed the survey. The mean age was 81.7 years, with 49% female. Most referrals were for cognitive issues (59%), followed by BPSD (13%), weight loss (9%), and falls (7%). The median Clinical Frailty Score was 4, indicating moderate to severe frailty. Regarding mobility, 77% were independent, 21% used an aid, and 2% were immobile. Cognitive assessments revealed 25% had normal cognition, 18% had mild impairment, and 57% had dementia.

Only 10% of patients were ideal for teleconsultations, while 90% faced significant barriers, such as environmental impairments (26), sensory impairments (2), and both (18). Additionally, 25% lacked computer, and only 10% used the internet regularly. Despite 59% having family assistance, overall, 82% had some form of environmental impairment. Sensory impairments were common, with 29% using hearing aids but 37% still experiencing issues. Visual impairments were better managed, with 76% wearing glasses.

Telemedicine adoption has accelerated due to COVID-19, but significant barriers for geriatric patients highlight the need for better support.

There is unequivocal evidence to support Perioperative care for the Older Person Undergoing Surgery (POPS) services. However, POPS services are not available in all Trusts offering surgery, including Royal Surrey Foundation Trust (RSFT). The necessity for POPS services will continue to grow with increasing numbers of older people undergoing elective and emergency surgery due to: changing demographics, surgical and anaesthetic advancements, shifts in culture and patients’ expectation of healthcare (1). A RSFT POPS steering group was convened to explore the current orthopaedic elective pathway, the what-why-how of implementing a POPS service and ultimately write a business case to submit to the board to request funding for a formal POPS service. Unfortunately, ahead of submitting we were informed a business case would unlikely secure funding due to the current financial climate. To continue to evidence the need for this service, over the course of a year, Geriatricians used their Supporting Professional Activities (SPA) time to provide informal POPS Comprehensive Geriatric Assessment (CGA) reviews to patients aged ≥65 with a CFS ≥5 on the elective waiting list for knee/hip operations. The average age of patients seen was 82 years (range 67-92). The average Clinical Frailty Score calculated was 7 (range 4-7) with the average number of frailty markers identified being 4 (range 1-7). Following CGA, 75% of patients decided not to proceed with operative management. 88% either initiated or completed a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT). We now have both local and national data to support the need for a POPS service at RSFT. When financial support is not available to invest in and develop new services, alternate methods such as staff re-distribution can be considered with the aim of both providing a service as well as collating invaluable evidence to support a business case and secure funding.

Introduction

Urinary incontinence significantly impacts the lives of older adults increasing their susceptibility to falls, social isolation and longterm care Intravesical Botulinum Toxin A (Botox) offers a well-established treatment for overactive bladders in women. In select centres, it can be administered under local anaesthetic, allowing access for frailer patients at higher risk from general anaesthetic and in whom anti-muscarinic therapies are best avoided. This project performed an analysis of geriatric patients who underwent intravesical Botox under local anaesthetic in an outpatient setting and assessed the tolerability and feasibility.

Method

50 women (mean age 66, range 34-88) with overactive bladders underwent Botox administration in 2023. The procedure utilised local anaesthesia (Instillagel) while patients held a supine position with abducted hips on an outpatient couch. A LiNA OperaScope and injeTAK® needle facilitated administration. A sub-analysis focused on patients aged 75+. Pain levels were compared to past cervical smear experiences for reference.

Results

All 50 patients successfully completed the procedure. 15 were aged 75+ (mean 80.8, range 76-88), with 8 classified as "frail" based on the Prisma 7 score (mean 2.3, range 0-5). The geriatric cohort reported lower average pain levels (1.8/10, range 1-3) compared to the non-geriatric group (2.2/10, range 1-5). Both groups pain perception was also lower than for past smears (2.9/10, range 1-4 vs. 3.4/10, range 1-7). Total ‘operative’ time was <3 minutes for all patients. Two non-geriatric participants experienced post-procedure UTIs, successfully treated with oral antibiotics (Clavien-Dindo II).

Conclusion

Intravesical Botox under local anaesthesia demonstrated promise as a safe and well-tolerated treatment for geriatric patients with overactive bladder, where lower levels of pain were reported compared to their younger counterparts. Tolerability was also better than previous smear tests and notably offers a relatable and novel comparison point to facilitate clearer counselling for patients and their families regarding this procedure.

Introduction 

Enhanced care units (ECU) are a novel concept, targeting the gap between ward-level and critical care. They care for patients requiring intensive medical or nursing care, who may not require, desire, or be suitable for, escalation above ward care (Society of Acute Medicine and Intensive Care Society, 2022). The ECU at Barnet Hospital opened in March 2022, and, because of the local population demographic, admits a high number of older patients living with frailty. We aimed to assess the performance of the ECU for this subset of patients. 

Methods

A retrospective audit of electronic records of 75 randomly selected patients admitted to ECU between March and August 2023. Data were gathered on Clinical Frailty Score (CFS) at baseline, comorbidity, escalation status, APACHE II illness severity score, and outcome measures. 

Results

The majority of patients in the sample, 52 of 75 (69.3%), were over 65 years of age with an average of 69.1 years. Baseline frailty score was high, with a modal CFS of 6. Of these patients, 32 (61.5%) had a DNACPR, and 16 (30.8%) had treatment ceiling at ECU level. Illness severity was similar across CFS groups, with a mean APACHE II score of 15.2 (representing a 25% mortality risk). Overall mortality in the over 65s was 23.1% (12/52), without significant change when stratified by CFS. Mortality in the under 65s was 8.7% (2/23). 

Conclusions 

Acutely unwell patients with frailty may benefit from ECU level care. In our centre, we found no significant increase in mortality linked to a higher frailty score. We suggest that this may represent good case selection by clinicians experienced in working with frailty: admitting patients with more reversibility and targeting therapies towards reversible causes. Limitations remain, especially in assessing illness severity, as the assessment tools are not targeted to this cohort.