CQ - Improved Access to Service

Introduction : 

The delayed discharge is defined as patient is deemed medically fit to leave hospital but is unable to do so for non-medical reasons. Delayed discharges are associated with mortality, infection, depression, reduction in patients' mobility and their daily activities. 

Aim and Objectives:

1.Recognition of different causes of discharge delays will allow health professionals, hospital administrators to propose potential strategies for minimising delays. 2.To identify causes of prolong delays in discharge among elderly patients.3. To propose strategies for eliminating advisable delays and improving healthcare delivery as well as patient flow process.

Methods:

Total 29 patients' data were collected at the same time. The average length of admission was 32 days. The data were collected to assessed likely presence of delayed discharges and reason for delayed discharges.

Results:

Total 19/29 ( 65% ) were medically fit for discharge (MFFD) and 10/29 ( 35% ) were not MFFD. The average length of time since being declared MFFD was 16days. The reasons for delayed discharges are awaiting POC (32%), awaiting placement (26%), awaiting furniture arrangement at home (10%), awaiting mental capacity assessment from social worker (10%), awaiting equipment delivery (5%), awaiting safeguarding outcomes (5%), awaiting family to find a property to be discharged (5%), family refused equipment (5%).

Recommendations

The recommendations are 1.completing early assessment of onward care needs and recognising the potential needs for either rehabilitation, home assessment for safety and need equipment or residential/nursing home. 2. Early discussion with patients and/or families to reduce the disagreement 3. Early communication with community teams like social worker and CCG by discharge team.

Conclusion

It is important to achieve the correct balance between minimising delays and not discharging patients from hospital before they are clinically ready.

Introduction

People with frailty (Rockwood Frailty Score of 4 or more) represents 43% of the medical take at Withybush Hospital. There was a lack of front door frailty and comprehensive geriatric assessments (CGA). It was postulated that this was leading to delays in discharge and limiting the number of patients receiving a CGA by teams led by a geriatrician

Methods

In mid-November 2022, the acute medical take was adapted to stream stable patients with frailty through a frailty assessment unit. Prior to this, the area was being used as a surge ward for short stay acute medical patients. On the frailty unit, patients receive a CGA creating a problem list and plan. The patients are then streamed into either short stay and discharged from the unit itself or to an appropriate ward area. Number of discharges was the main outcome measure.

Results

In the 2 months preceding the intervention the number of discharges from the short stay assessment unit was 16% of total medical discharges. The percentage of patient’s discharged from frailty wards was also 16% of medical discharges. In the 2 months after the intervention, discharges from the frailty unit accounted for 21% of medical discharges. Discharges from the frailty wards accounted for 16% of medical discharges. In the post intervention months, the frailty team discharges accounted for 37% of total medical discharges. 

Conclusions

Adoption of frailty unit model improved rates of short stay discharges and allowed frailty team to assess a greater proportion of the hospital patients. Using assessment by the frailty teams as a surrogate for a CGA this has significantly improved the proportion of patients receiving CGA to more fit our patient demographics.

Introduction

The prevalence of eye disease and visual impairment in care home residents is disproportionately higher compared to the general population. Access to eye care services and treatment can be variable for this vulnerable population.

Objective

This narrative synthesis reviews the available evidence of services and interventions for delivering eye care to care home residents. The key review questions: 1. What is the existing evidence for eye care interventions or services (including service configuration) for care home residents? 2. Does the provision of these interventions or services improve outcomes?

Methods

Literature search of EMBASE/MEDLINE for original papers published since 1995. Two reviewers independently reviewed abstracts/papers. Data was extracted and evaluated using narrative synthesis.

Results

13 original papers met the inclusion criteria. On-site optometrist-led services improved diagnosis and management of eye conditions, with one study showing 53% of residents benefited from direct ophthalmology intervention. Provision of interventions such as cataract surgery, refractive error correction and low vision rehabilitation improved visual acuity and vision-related quality of life but did not improve cognitive or physical function, depression or health-related quality of life. There was little UK-based literature to inform eye service design or interventions to improve outcomes.

Conclusion

Care home based eye assessments improve the management of eye conditions. Interventions improve visual acuity and vision-related quality of life. Further research and/or clinical service scoping is needed to better understand current UK services, access difficulties or examples of good practice as well as to identify and test cost-effective service models for this vulnerable group.

Introduction

It is well recognised that patients with Parkinson’s disease (PD) have significant symptom burden in advanced stages of their disease. Integration of movement disorder and palliative care services has been limited by concerns about resource and sustainability. We present our experience of establishing a movement disorders palliative care multidisciplinary meeting. Method In 2019 we established a multidisciplinary virtual bimonthly meeting between movement disorders and palliative care specialists. Referrals were accepted from movement disorder specialists, community Parkinson’s practitioners and palliative care specialists. Referring clinicians all actively applied primary palliative care approaches within their existing services.

Aims of the meeting were to facilitate holistic management of complex needs, support advance care planning (ACP) and consider referral to specialist palliative care services. Result 37 patients in total were discussed over a 2-year period (although the service was limited for a time due to COVID pressures). On average 3 new patients were discussed per meeting. Reasons for referral included motor and non-motor symptoms, support with ACP, medication advice, caregiver concerns and emotional distress.

Meeting outcomes included medication adjustments, expediting reviews, hospice support, carer support, and referral to other services. Since the meetings started 23 (62%) patients have died. Of these, 30% died in hospital compared with the national average of 43.4%. The average between discussion at the meeting and death was 139 days. The meeting has generated education opportunities, triggered joint assessments and a professionals’ framework for the palliative management of patients with a movement disorder.

Conclusions

We present the experience of an MDT embedded within an early integrated palliative care service for movement disorders. The MDT has strengthened partnership working and findings suggest that alongside active primary palliative care, specialist palliative care for PD can be sustainable and resource efficient in a UK setting.

Introduction

NICE guidelines state that fracture risk assessment should occur in all women aged ≥65 and all men aged ≥75. This includes assessing patients’ FRAX score, measuring serum vitamin D and calcium levels. Early detection and treatment can prevent complications like fragility fractures. We conducted a Quality Improvement Project to improve bone health assessments on Geriatric Wards.

Methods

A baseline audit assessed: admission reason, falls history, FRAX score, CFS, previous DEXA scans, whether vitamin D and calcium levels were checked during the admission, and if treatment was commenced (bone resorption medication and vitamin D/calcium supplements). Data was collected two further times following interventions over a 5-month period. The first intervention was an announcement at the morning departmental meeting reminding clinicians. The second intervention was an email reminder.

Results

There were 56, 51, and 58 patients per cycle. 19, 15, and 17 patients were admitted with falls. 23, 14, and 10 patients had a falls history. Average CFS was 5.4, 5.4, and 5.5. Average major osteoporotic fracture FRAX score was 15.8, 16.4, and 12.9. Checking serum calcium was 88%, 100%, and 100%. Checking vitamin D was 30%, 43%, and 60%. 28%, 43%, and 47% of patients were prescribed calcium and vitamin D supplements. Patients on bone resorptive treatment dropped from 7% to 3% to 2%. 8, 12, and 11 patients had a previous DEXA.

Discussion

Verbal announcement had the greatest impact. Visible reminders help sustainability. This QIP highlighted the lack of bone protection treatment with multiple contributing factors including some patients lacking the capacity to follow instructions to take weekly medications or patients requiring vitamin D being replaced initially, with initiation later. This QIP feeds into a larger trust project in developing a ‘Fracture Liaison Service’, which could improve adherence and provide a pathway in utilising annual and bi-annual treatments.

Introduction:

Older patients undergoing surgery are often living with frailty and are subsequently at increased risk of morbidity, mortality and loss of independence in the perioperative period. Accurate identification of frailty using an objective tool such as the Clinical Frailty Scale (CFS) is an imperative part of preoperative risk assessment. It also informs which patients should undergo Comprehensive Geriatric Assessment (CGA) by our Perioperative care of Older People undergoing Surgery (POPS) service.

Method:

The POPS team provided training to Surgical Assessment Unit (SAU) triage staff over a week-long period, including how to calculate and record the CFS electronically for all patients age 65 and over presenting to the unit. Once embedded, accuracy was assessed by comparing triage staff CFS scores with those calculated by the POPS team.

Results:

Fourteen SAU staff members received training. There has been a 20% initial increase in the CFS scoring compliance from 22% to 42%. Compliance has been variable and impacted by several factors including relocation of the unit and new staff members. At its peak compliance was 67% - attributed to a change in data entry procedure with the ward clerk entering the score following triage, which improved electronic capture. CFS scoring accuracy was reviewed over 7-weeks. Of the 39 CFS scores compared there were 5 matches, 8 non-matches, 19 without a CFS recorded by triage staff and 8 not recorded for other reasons. All of those not matching were underestimated by up to three CFS scoring intervals.

Conclusion:

There has been an increase in CFS scoring compliance within SAU. Further improvement work is required to increase the number being assessed and improve the accuracy of scoring. Further staff training, initiation of a ‘frailty champion’ in SAU and visual prompts including a display board are planned to increase and sustain CFS compliance and accuracy.

Aim:

There been several studies validating the Hospital Frailty Risk Score (HFRS) to identify frailty. (1),(2). We proposed that it could identify patients in the Emergency Department (ED) who would benefit from the Older Persons Assessment Service (OPAS).

Methods:

OPAS is an ED service which accepts patients on frailty criteria (aged >70 years, falls, confusion, care dependence, polypharmacy and poor mobility). A retrospective analysis of the OPAS databank was conducted using HFRS to divide patients in High/Intermediate and Low Frailty Risk. We considered Age, Clinical Frailty Score (CFS), Post-code with Deprivation Index and death within a year of attendance.

Results:

700 admissions: 400 High/Intermediate HFRS and 300 Low HFRS. High/Intermediate HFRS: 170 (42.5%) male, mean age 83.69 years, CFS 5.7. Low HFRS: 102 (34%) male, mean age 81.46 years, CFS 4.5. High HFRS vs Low HFRS had similar deaths (p=0.2) but a significant difference in CFS (p<0.05). HFRS was significant at detecting frailty in those <75 years old (p<0.01) but not at >76 (p=0.08). There was no association between the Welsh index of multiple deprivation with Frailty or Death. The HFRS Sensitivity is 0.44, Specificity 0.83, Positive Predictive Value 0.66, Negative Predictive value 0.34, Area under the curve 0.39 vs CFS.

Conclusion:

The HFRS identified 57% of the retrospective OPAS cohort, with the addition of >80yrs of age, the modified score identifies >85% of service users. We found that controlling for socio-economic status, quality of discharge summaries and coding had no relationship to the efficacy of HFRS as a screening tool. We have developed an electronic, automated Frailty Flag that operates in real-time to signpost appropriate patients who would benefit from OPAS, Orthogeriatric or POPs services (this facilitates patients to be ‘flagged’ for review as stated within NELA.) The Frailty flag is currently being tested in clinical practice.