CQ - Improved Access to Service

Introduction

Oncogeriatrics is relatively new concept aligning geriatric services with oncology, whereby older cancer patients have a comprehensive geriatrics assessment (CGA) to support oncology decision-making and improve outcomes and quality of care. Despite the rationale, evidence for effective oncogeriatric services are largely based upon specialist centres. We initiated a feasibility study February 2021, to establish criteria and pathway implications for an Acute Trust without oncology beds.

Method

Following an iterative process, a pathway was established between the Lung MDT and the established frailty unit. Patients with lung cancer who met criteria would be seen within a week and underwent a CGA by a frailty practitioner, consultant geriatrician, physiotherapist, occupational therapist. Referrals were made as appropriate to allied services eg dietician, pharmacy, continence teams etc.

Results

We refined the referral criteria and process, identifying the presence of a geriatrician at Lung MDT as key to ensuring incorporation of CFS (Rockwood) for effective MDT case discussion. Defining the cohort and pathway was challenging given the complex interplay of cancer symptom burden and comorbidity set against COVID, workforce pressures and cancer targets. Final referral criteria was age over 70, Rockwood 4 or more, a formal lung cancer diagnosis, and a plan to undergo active treatment. Referral numbers were low during the feasibility phase. Only 38 patients were referred and we saw 23 patients over a 2 year period. Referral rates increased in the final 3 months of the pilot although only 9 of 22 who met criteria were referred.

Conclusion

Establishment of an effective oncogeriatrics service is challenging. The feasibility study has established a baseline for potential activity and job planning. Analysis of individual patient benefit is ongoing. Longer term we aim to extend the service to support patients after treatment has started, provide prehab, and include patients with all types of cancer.

Background

The East Kent Frailty Home Treatment Service (Frailty HTS) provides person-centred, hospital-level care for people living with frailty. The Frailty HTS can diagnose and treat acute medical illness at home or in care homes. The team philosophy is “we identify what you want and strive to make it happen”. This project was underpinned by advance care planning for people living in care homes, which the frailty team supports through proactive work with the primary care network care homes teams.

Frailty is associated with increased healthcare costs and poor outcomes associated with hospitalisation. The acute hospitals were under extreme pressure. The Frailty HTS serves 360 care homes.

Methods

Carers and the ambulance service discuss all acutely unwell care home residents with the Frailty HTS prior to conveyance except in the case of a long bone fracture or acute cardiac/cardiovascular event (unless care plan is not for escalation).

There were communications initiatives to care homes and Ambulance Trust explaining referral process and eligibility. A dedicated frailty HTS clinician was available to respond to calls.

Results

The pilot has seen an increase in referrals of people living in care homes from SECAMB to Frailty HTS (monthly average up from 49 up to 64) an increase in direct referral from care homes (monthly average up from 15 to 21.5). We also saw a reduction in attendance of care home residents at ED (monthly average down from 276 to 209) and reduced admissions to hospital from care homes (monthly average down from 203 to 191).

Conclusion

This project raised awareness of an alternative to acute hospital care for people living in care homes. Referrals to the Frailty HTS were increased and attendance at ED and admissions to hospital reduced.  Due to system pressures it continued to run and became business as usual.

Background: North Middlesex University Hospital runs an outpatient frailty service offering Comprehensive Geriatric Assessment. There is a daily ‘hot slot’ for patients who may otherwise require unplanned admission if not seen within seven days. Aim was to improve slot utilisation from 50 to 100%, with appropriate admission avoidance referrals by June 2023. Empty slots result in an inefficient use of resources, increased workload in other departments and reduced opportunity for patients to benefit from the service. 

Methods: We audited hot slots in November and December 2022, marking slots as ‘filled’ or ‘unfilled’. In January 2023 we established a clear referral process for hot slots, implemented an education programme to increase awareness of the availability and referral criteria, and increased Consultant availability in the department. We then re-audited the hot slots from February to April 2023 and analysed data, conducted statistical testing and produced visual representation of the data.  

Results: After exclusion of periods where hot slots were closed (n=13) including industrial action, bank holidays and times with below minimum staffing; 82 slots were audited, pre-intervention (n=39) and post-intervention (n=43). The utilisation of hot slots increased from 51% pre-intervention to 86% post-intervention. Fisher's exact test showed statistical significance (p<0.0007). Intervention did not improve appropriate use of hot slots (41% to 35%). 

Conclusions: Interventions increased utilisation of hot slots but fell short of the targeted 100% utilisation rate. We plan to make the hot slot available exclusively to the Geriatric Emergency Medicine (GEM) team for one week in August to assess whether this increases utilisation of the hot slot. We intend to further analyse the data to review the appropriateness of referrals and help identify other ways to improve this. We anticipate our service will expand frailty frontline provision plans to help meet rising need for urgent outpatient frailty care. 

Introduction:

Recent studies show the use of comprehensive geriatric assessment (CGA) in older patients with cancer can result in better quality of life, improved treatment tolerance and reduced hospital admissions, leading to international consensus that CGA should be routinely included in care. We have piloted an onco-geriatric MDT, consisting of oncologists, geriatricians and therapy input, alongside a rapid-access geriatrician-led onco-geriatric clinic

Method:

Referrals were invited from oncologists for older patients (>70) with a new diagnosis of cancer, with expected prognosis of more than 1 year, about whom they had concerns regarding their ability to undergo radical treatment due to co-morbidities, falls, cognitive impairment or social isolation. A CGA was completed prior to starting radical treatment in most cases. Performance status, Rockwood frailty score(RFS) and G8 score were calculated for all patients.

Results:

During the 24 week trial period, an MDT and clinic has run every week. A total of 32 patients have been discussed at MDT, with 22 seen in clinic, from cancer sites including colorectal, breast, urological and ovarian. Patient seen in clinic had an average RFS of 4.5 and G8 score of 13. All patients have seen a geriatrician, with most also seeing our physiotherapist. Interventions included medication review and rationalisation, anaemia review and treatment, referral to specialist memory and continence services, blood pressure optimisation and completion of a treatment escalation plan.

Conclusions:

Feedback from patients attending the clinic has been resoundingly positive, with 100% of patients rating their service experience as “good” or “very good” and praising the time to talk about their health as a whole. Follow up of clinic patients is in progress, identifying emergency admissions alongside treatment toxicities and complications within this group, as well as whether G8 is an appropriate screening tool for clinic review, to secure the long-term future of the service.

Introduction: The Community Geriatrician team based at the Countess of Chester Hospital is a multidisciplinary team offering comprehensive assessments at home to older patients with frailty. The team review frail patients identified as being at risk of hospital admission. Cognitive impairment and dementia are increasingly common concerns in our patient group and significant risk factors for admission. Frail patients often struggle to access traditional memory clinics for a variety of reasons and can therefore remain undiagnosed. They often require a more holistic approach in their home environment. We therefore identified a need to offer a dedicated frailty memory pathway within our community geriatrician team enabling better access to dementia assessment and diagnosis in complex frail patients.

Method: A frailty memory assessment pathway was proposed and commenced in 2022. Following identification of a cognitive concern during the initial comprehensive geriatric assessment a further home visit is arranged to assess memory in more depth. Patients are then discussed, and a diagnosis reached via a monthly Frailty memory MDT attended by Consultant psychiatrist, Consultant geriatrician, and Specialist Occupational therapist. Following delivery of a diagnosis our AGE UK well-being coordinator within the team provides post diagnostic support and sign posting to patient and family. A retrospective audit was undertaken reviewing the 44 patients diagnosed since pathway commenced. The number of hospital admissions and number of inpatient bed days was compared in the 3 months pre and post initial assessment.

Results: In the 3 months following assessment 82% of patients had a reduction or unchanged number of admissions, there was a total reduction of 71 inpatient bed days.

Conclusion: We believe our pathway offers a unique multidisciplinary approach to dementia diagnosis in the frail population, improving frail patients access to dementia assessment with a reduction in hospital admissions.

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 frailty at the front door or a 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’.

Introduction:

The benefits of early frailty scoring for patients over 65 presenting to emergency settings are well established. A scoping exercise in the Emergency Department (ED) at the University Hospital of Wales (UHW) identified lack of familiarity with the Clinical Frailty Scale (CFS) and time pressures as barriers to achieving frailty screening at triage. In response, the Frailty Intervention Team (FIT) at UHW developed the Self-Assessment of Frailty in the Emergency Settings Tool (SAFE-T).

Methods:

A PDSA cycle was performed to assess SAFE-T validity and the feasibility of implementation in ED and in a community intermediate care clinic. A 5-day pilot was conducted in April 2023 where all patients >65 years were asked to complete and return a SAFE-T. In parallel, blinded to the result of the SAFE-T, the FIT team completed a CFS score and the results were compared. Process feedback was collected from the FIT team, ED staff and hospital volunteers to identify implementation barriers.

Results:

Data were analysed from 58 questionnaires (50 from ED, 8 from Community Clinic). 42 participants completed SAFE-T alone, 16 completed it with support (e.g. family advocate/hospital volunteer). 7 were excluded from final analysis due to insufficient data to enable comparison. Initial results indicate that the SAFE-T is a sensitive screening tool for frailty and that sensitivity maybe improved where the patient is supported by a collateral informant. Process feedback identified problems with SAFE-T layout, resource implications and the perceived labour intensiveness of the tool.

Conclusions:

SAFE-T is a sensitive tool for the identification of frailty in different clinical settings. Process feedback suggests that further development of the tool will improve ease of use for patients and healthcare professionals. A further PDSA cycle is now underway to assess how the tool may assist in improving compliance with frailty scoring in ED

University Hospital Plymouth (UHP) provides secondary care to 475,000 people with a wider population of almost 2,000,000 people who can access its specialist services.

COVID pandemic had a significant impact of the outpatient list within the UHP NHS Trust and demonstrated that previously well-established model of Falls clinic was no longer fit for purpose. This resulted in a significant delay in waiting times for patients awaiting a specialist review.

A new model was designed to address issues and reduce waiting times for patients with Falls in the catchment area. The Pilot Multidisciplinary Team (MDT) Falls Clinic was introduced in July 2022 where patients are seen by a Falls Specialist Nurse, Advanced Pharmacist and Advanced Physiotherapist on the same day. All patients then are discussed at weekly virtual MDT meeting with Consultant Geriatrician where a decision is made whether patient could be discharged back to the Primary Care.

117 out of 149 patients have been booked into clinic. Only 57 patients (47%) were referred forward to the 1st Medical clinic. Out of 57 patients 31 have been seen and 10 were discharged back to GP following clinic attendance.

60 patients (51%) were discharged following review at the Pilot MDT Falls Clinic. 7 patients were re-admitted within the next 6 months after been discharged from the Pilot MDT Falls clinic. However, none of the admissions were related to Falls.

The waiting times were reduced by 4 months.

Funding was secured to run the clinic for the 12 months and the next step is to expand the team by employing another Advanced Pharmacist and Physiotherapist. The Pilot MDT Falls clinic demonstrated that a new approach is beneficial to patients. It also supports development of the skills for all team members though sharing expertise, knowledge and skills, and building team rapport.

 Introduction In the presence of multiple co-morbidities and frailty, older people undergoing emergency laparotomy warrant higher supportive care. It is evident that geriatrician input to perioperative care plays a crucial role to improve patient experience and outcomes ( 1, 2). Whilst we recognised the need for a surgical liaison service and increased compliance with NELA we had limited resources to give. We created an automatic email alert to enable us to see NELA patients and make the maximum use of our clinical time. Method An automated email alert was created in July 2022 to identify patients undergoing laparotomy based on theatre coding, we then set up filtering by age and frailty. A surgical liaison service was already established but we were able to target NELA patients from September 2022. Retrospective analysis of local data for Morriston Hospital extracted from 2022 National Emergency Laparotomy Audit allowed comparison of compliance to expected standards by the SOPAS (surgical liaison) service before and after intervention. Results There were 225 patients who required emergency laparotomy at Morriston hospital in 2022. 50 patients met NELA criteria of which 30% were > 64 with high CFS and 70% over 80. A 3 month period (March-May) prior to the intervention and 3 months following (Sept-Nov). We showed an increased in compliance with NELA standards from under 10% to over 50% with this intervention. Conclusion Significant improvement of 5% to 50% compliance with NELA standards was observed after the intervention of email alert; further to this we noted an issue with the alert working through December 2022 where many patients were not seen. This corresponded with a period of increased mortality. Our aim going forward is to upscale this to align with the BGS Position Statement. (3

Introduction

It is well recognized frailty is increasing amongst the population and can impact on outcomes for patients when admitted to hospital.  Frail older adults are more vulnerable to developing complications form continued hospital admissions. National recommendations by GIRFT indicate CFS scores ought to be documented in the Emergency Department (ED) to facilitate early recognition of frailty and stream patient to the appropriate pathway and clinician. The aim of this is to ensure the correct Clinician reviews the frailer adult in the most appropriate setting and thereby reduce risk of deterioration and patient harm.  In October 2022. Bolton NHS Trust created a dedicated frailty unit staffed by Geriatricians for older frail adults.  Therefore, a method of identifying and streaming frailer older adults is crucial to effectiveness of the unit. This was embedded into Electronic Patient Record (EPR) system.

Methods

PDSA cycles were implemented. A retrospective audit was performed prior to the implementation of the CFS documentation.

A robust education programme was introduced to all clinical staff in the Emergency Department. Online modules were also available. A second audit as part of PDSA cycle was then performed to assess the intervention.

Results

Pre-intervention and EPR documentation tool only 11% of patients had CFS score. Following the intervention, 88% of medical staff included the CFS score in their assessment prior to a Frailty team referral and review. The frailty team have observed an increase in referrals.

Conclusions

Early recognition and documentation has enabled improved streaming and review of the correct patients to the frailty unit.  This has enabled Gold Standard of Comprehensive Geriatric Assessment for frailer adults to be completed.  Further PDSA cycles to the effectiveness of the unit are ongoing. Initial data indicates with correct identification and recognition of frailty; the average length of stay has reduced.