CQ - Improved Access to Service

INTRODUCTION: Guidance around optimal management of patients with cognitive impairment within a Parkinson’s disease (PD) multidisciplinary team (MDT) is lacking. This project aimed to improve the service pathway by integrating a Parkinson’s disease specialist psychiatrist (PDSP) within the MDT rather than referring patients to a separate mental health service.

METHODS: Data including mental health symptoms, time to review, diagnosis, treatment, and follow-up were collected over 12 months from the electronic clinical records of all patients referred to the PDSP with cognitive impairment. This data set was subject to descriptive analysis and economic evaluations.

RESULTS: 47 patients with Parkinson’s and cognitive impairment were referred to the PDSP - median waiting time to review was one month. Fourteen patients were diagnosed with mild cognitive impairment, 5 with dementia, and 28 with another condition or requiring further diagnostic assessment. Review with the PDSP prevented onward referral to another service in 29 cases, saving an estimated £1140 and reducing duplication of assessments.

CONCLUSIONS: Integration of a PDSP into a PD MDT avoided the need to refer the majority of patients to a separate mental health service, led to fewer health care professional contacts, reduced duplication, and cost savings. It is likely that the model led to earlier diagnoses and treatment. Evidence as to patient and carer experience is not yet available.

Over the last 12 months, an oncogeriatric clinic was successfully established to assess frail 2-week wait (2WW) patients referred with upper and lower gastrointestinal (GI) symptoms. The clinic was initially funded by the West Yorkshire Cancer Alliance, enabling a weekly clinic, run by a geriatrician, clinical specialist nurse and an advance clinical practitioner. A total of 350 patients were assessed, with only a third of them remaining on the 2WW pathway compared to traditional surgical patients; this was due to patients being too frail or an alternative diagnosis being made through comprehensive geriatric assessment, and a shared decision-making process. Patients with a clinical frailty score of 6 or more were eligible for referral, and due to demand exceeding capacity, remaining patients were referred on through the default surgical or GI pathways. Patients were triaged by endoscopy nurses from ‘straight to test’ referrals after training provided to assess frailty scores using routinely data available. The patient level information and costing system (PLICS) demonstrated that the oncogeriatric was a cost effective clinic, costing approximately £340 less per patient than the default pathways of care. Feedback from patients demonstrated extremely high satisfaction rates with the service provided. One of the most significant interventions was medicines management, which has led to a pharmacist supporting the clinic through further innovation funding. Lessons learned included developing a better understanding of cancer diagnosis and frailty, providing a ‘one stop centre’ for cancer care, and managing complex comorbid conditions in frail older people suspected of having cancer. As a result of this QI service development project, a Frailty Cancer Strategy for the Trust has been developed and will be presented to the executive team with the aim of developing a comprehensive oncogeriatric service for frail patients in Leeds, providing the right care, and right treatment first time.

Introduction:

Frailty is the concept of increasing vulnerability to minor stressors in the context of a reduction in physiological reserves (Clegg et Al. The Lancet 2013, Volume 381, pages 752-762). It affects 10% of people presenting to Emergency departments (ED) and around 30% of inpatients in acute medical units (NHS England and NHS Improvements. 2019). Implementing a CGA is known to result in a significant increase in your likelihood of being alive and in your own home at 6 months (Ellis et Al. BMJ 2013).
 

Aims:

To implement an ED in reach frailty service with the goal of performing a CGA at the earliest opportunity.
 

Methods:

We undertook a 3 week pilot with a small team comprising a consultant, frailty ACP, SHO and geriatric registrar. The team were based in ED and worked alongside the existing ED navigator team and in conjunction with various community teams. Data was collected assessing completion of the usual domains within the CGA and discharge data.

Results:

62 patients were seen in total. Mean age was 82.4 years with a mean CFS of 5. Each patient received a CGA. 9/62 (15%) of patients were discharged on the same day. 15/53 (28%) were discharged within 72 hours of admission. Other notable results include: 100% completion of 4AT and 70 medications de-prescribed. Feedback from patient and relatives in addition to ED and AMU doctors was extremely positive.
 

Conclusion:

We demonstrated that performing a CGA in ED resulted in higher numbers of patients being discharged on the same day or within 72 hours of admission. We were able to demonstrate a significant increase in assessment of delirium allowing earlier detection and a much higher rate of deprescribing with significant benefits for both patient and the trust.

This poster demonstrates how a hospital at home team (the Acute Clinical Team (ACT), Neath Port Talbot) piloted an early intervention scheme, in care homes to prevent admission to hospital. 

Instead of waiting for care homes to contact the service when residents became unwell, during the second wave of COVID 19, the ACT proactively rang care homes three times weekly to seek out the acutely unwell patients and provide acute medical and nursing care quickly and efficiently. With GP's unable to visit the care residents at the rate required and avoidable hospital admissions rising, the pilot sought to improve medical care for the frail older person, without having to leave their care homes. 

With full clinical responsibility and use of thorough medical assessments from Advanced Clinical Practitioners and Consultant Geriatrician oversight, use of the point of care blood results and being able to deliver IV fluids, IV antibiotics and IV diuretics and more. The results of the pilot which are demonstrated in the poster show how successful early intervention can be for this population group.

A short video is also attached to introduce the ACT team and describe the pilot.  

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Background:

The UK has an increasingly frail ageing population, with rising numbers presenting to Emergency Departments (ED’s), with subsequent admission to hospital wards. Older adults living with frailty have longer waiting times in ED’s, are more likely to be admitted and have longer lengths of stay.

Introduction:

The NHS Long Term Plan requires hospitals to provide an Acute Frailty Service (AFS) for at least 70 hours/week and complete a Clinical Frailty Score (CFS) within 30 minutes of arrival3 . The plan also advocates Same Day Emergency Care (SDEC) to reduce admission related harms and discharge patients in a timely way4 . The introduction of an acute frailty CQUIN stipulating prompt identification of frailty and initiation of CGA is another driver for the development of AFS5 .

Method:

An Acute Frailty SDEC Team was established, including an Acute Frailty Nurse, Clinical Fellow, Advanced Clinical Practitioners and GPs. The team was present in ED on weekdays between 9am-5pm, with 1-2 team members on each shift. A Consultant Geriatrician was also available to provide advice and support. A Frailty SDEC inclusion criteria was recommended as follows:

- Age >=65years with CFS>=5

– NEWS<3 - Triage note suggests patient may not need hospital admission> <3

- Triage note suggests patient may not need hospital admission

Results:

Over a 4-month period, 262 patients were seen by the SDEC team. Age and CFS score for this population are shown in Figure 1 and 2. 74% were seen within 2hours as demonstrated in Figure 3.

131 (50%) of patients were discharged directly from ED (Figure 4). A further 25 (15%) of patients were later discharged from EAU.

Conclusion:

An Acute Frailty SDEC service results in early identification of frailty, timely assessment in ED and a high likelihood of discharge (60%) directly from ED or EAU rather than being admitted to an inpatient ward. Implementation of a 7 day service would only serve to increase these figures.

References:

1. Nuffield Trust (2014) Focus on: A&E attendances. https://www.nuffieldtrust.org.uk/research/focus-on-a[1]e-attendances 2. The King’s Fund (2012) Older People and Emergency Bed Use. https://www.kingsfund.org.uk/sites/default/files/field/field_publicatio… 3. NHS (2019) The NHS long term plan. https://www.longtermplan.nhs.uk/ 4. NHS Improvement, NHS England, the Ambulatory Emergency Care Network and the Acute Frailty Network. (2019) Same-day acute frailty services. SDEC_guide_frailty_May_2019_update.pdf (england.nhs.uk) 5. NHS (2023) Commissioning for Quality and Innovation (CQUIN) scheme for 2023/24 . Annex: Indicator specifications. CQUIN-scheme-for-2023-24-indicator-specifications-version-1.1.pdf (england.nhs.uk)

Introduction:

In 2019, the Royal College of Physicians (RCP) advised that all patients should have their vision screened if identified as a falls risk. Our aim was to implement a bedside visual screening test and establish an onward inpatient referral to Hospital Eye Services (HES).

Method:

This is a collaborative Quality Improvement project involving Geriatric Medicine, HES and the Royal National Institute of Blind People (RNIB). A pilot study cross referenced falls admissions with previous known ophthalmic data to estimate the proportion of known vision loss in this group. In the second phase of the project, a bedside visual screening test has been introduced for all patients admitted to COTE with a fall. Patients failing the screening are reviewed by an RNIB Eye Clinic Liasion Officer (ECLO) and if necessary, a prompt inpatient HES review is arranged.

Results:

Of 182 patients admitted following a fall, in the pilot study, 112 (61%) were known to ophthalmology previously. Of patients known to ophthalmology, 28 (25%) had vision of 6/18 or worse and would be considered to struggle with daily living tasks. 12 (10%) had a certificate of visual impairment (CVI) and 3 (3%) were eligible for CVI but had not been previously registered. One year following implementation of bedside vision testing, 287 patients had been reviewed after failing bedside screening. 97 of these had an onward referral sent or an intervention performed. The first ‘COTE ECLO’ post has been funded as a result of this work.

Conclusion:

Assessing vision is a critical element of the assessment of patients with falls. Through collaboration with the RNIB and Ophthalmology a successful pathway has been developed to address visual impairment in this vulnerable group of patients.

Introduction:

 It is recognised that there are pressures on the NHS particularly the emergency services.  Therefore, a focus of the 21/22 Priorities and Operational Guidance was to develop community services to prevent emergency department (ED) attendance and avoidable hospital admissions.  This informed the funding of urgent community response services (UCR).  An urgent response is defined as a presentation that would likely result in hospital admission if a response were not made within 2 hours.  Quality Improvement methodology was applied to evaluate the potential impact an advance clinical practitioner (ACP) could have in providing alternatives to hospital conveyance by redirecting appropriate calls to the UCR. 

Method:

Small scale tests of change with iterations of Plan Do Study Act cycles were conducted to enable comparison and recommendation for the use of the funding.  PDSA 1.  ACP based in an ambulance station. PDSA 2 and 4 ACP based in 2 different hospital EDs at the point of triage.  PDSA 3.  ACP based in the clinical hub where 111 calls are triaged.  

Results:

These PDSA cycles enabled process mapping of the patient journey to be made and a gap analysis showed the possible interventions an ACP to make to prevent an inappropriate admission.  It was apparent that a call stack pull model where the ACP can directly respond to calls from the ambulance list, and often redirect to the UCR service, was the most effective method.  Cross organisational information governance issues were found to be a barrier to implementation.

Conclusion:

Small-scale tests of change were implemented to seek the most effective use of an ACP to support alternatives to hospital admission. To introduce this pathway, a whole systems approach is needed to collaboratively provide a seamless service and an overall better experience for all.

Aim:  Several patient selection scores have been developed to identify patients suitable for SDEC from triage in Emergency Departments (ED) and the acute medical intake. Scores are designed to improve system efficiency, overcrowding and patient experience.  Studies have been conducted that compare these; none in frail older adults. This study compared the Glasgow Admission Prediction Score (GAPS), Sydney Triage to Admission Risk Tool (START) and the Ambulatory Score (Amb). 

Methods: The Older Person’s Assessment service (OPAS) is ED based, accepting patients with frailty syndromes aged >70 years with same-day discharge for >75% of patients. The OPAS databank was retrospectively analysed and interactions with age, Charlson Co-morbidity index (CCI) and Clinical Frailty Score (CFS) were evaluated alongside each ambulatory score. ED documentation was used to gain triage data.   

Results: 748 attendances, 274(36.6%) Male with mean age 82.8(±8.5) years, CFS 5.2(±1.4) and CCI 6.7(±2.6) with 584(78.1%) discharged same day.  Mean Amb 4.2(±1.7), GAPS 21.4(±5.8), START 23.5(±4.7) scores all within admission range with 29.1% Mortality within 12 months. There was a significant difference between those admitted and discharged with CFS (p<0.001) and mortality (p<0.001).

Conclusion:  Frailty is an important determinant in identifying whether ambulatory care is appropriate. No score could be reliably used as a screen for suitable patients for SDEC services although the Amb score was the most accurate when assessing each individual variable. We are developing our own SDEC score for older, frailer adults which is currently being validated in the OPAS and SDEC settings. 

Introduction

Causeway Hospital’s frailty service consists of an Acute Elder Medicine/Stroke unit of 30 inpatient beds and a Frailty Direct Assessment Unit (DAU) for GP referrals and EmergenIntroductioncy Department (ED) patients suitable for same-day turnaround with comprehensive geriatric assessment (CGA) from our multidisciplinary team. 

We have devised a new Frailty Model to enhance our service, maximise integration between primary and secondary care services and facilitate more effective short-stay care and early supported discharge. 

Method

To initiate this model, we plan to: 

1. Strengthen our DAU admission pathways – by identifying ED patients more quickly, promoting anticipatory care pathways, and ensuring all GP’s in the Causeway locality are made aware of the direct referral pathway. 

2. Explore new ways of working within DAU – by collaborating with the NI Ambulance Service to develop a direct access pathway to DAU for patients meeting specific criteria (e.g. non-injurious falls), and setting up pathways for residential homes (offering CGA in DAU for new permanent admissions into residential homes). 

3. Open an Acute Frailty Unit – by developing a 6-bedded Acute Elderly Area, and testing a model in the coming months to assess the long-term viability of this project. 

Results

We expect early results for the impact of this model in the coming months, and hope our enhanced service will provide comprehensive short-stay care and support timely discharge back to the community with a safe wrap-around service. 

Conclusion

To meet the increasing needs of today’s ageing population, we need pathways that decrease reliance on acute secondary care services, promote independent living for frail, older people where possible and strengthen our relationship with primary care colleagues. 

Our Frailty Model aims to streamline services and create new ways of ensuring our older population are given the best chance to have a healthy, fulfilling and well-supported later life.

Introduction: The Frailty Intervention Team (FIT) is a multidisciplinary team that provides a service to community based frail adults. This particular service is novel in the sense that it is a hospital based out-patient service as opposed to community based service and has access to rapid diagnostic and intervention services. Aims: The aim of this research is to share and describe the model of this relatively new and novel service for the benefit of other service providers. Method: A prospective database review was performed to provide descriptive data on the service between 2021 & 2022. Variables examined included referral source, MDT members involved on initial assessment and follow up, patient’s objective outcome measures and a history of falls. Result: Between the years 2021 and 2022, 350 new patients and 912 review patients were seen by the team with an additional 139 Medical Assessment Unit consultations carried out also. Of these service users 37.38% were male and 62.61% female. The average Clinical Frailty Score was 4.98 (4.91 men, 5.05 women). This indicates the mean service users is ‘Living with Mild Frailty’ - a cohort that may be otherwise missed by other services. Conclusion: This research highlights the demand for access to out-patient frailty interventions in line with the National Clinical Programme for Older Persons which promotes access to ‘the right person, in the right place, at the right time’.