Education

Introduction

Although hearing loss is the foremost cause of years lived with disability in people over 70, it remains commonly underrecognised ^[1,2]. Health of the UK signing deaf community is reportedly worse than the general population, often due to resulting undertreatment of associated co-morbidities including visual impairment, falls and dementia ^[3,4].

Local Problem

There is an estimated 21% prevalence of ≥25dBHL hearing loss within the Wolverhampton adult population, this increasing with age ^[5]. A large number of inpatients admitted to the Older Adult Medicine (OAM) wards at New Cross Hospital have clinically evident sensory impairment, impacting upon interactions with healthcare staff. This project identified the current methods through which hearing and/or visual impairment is formally screened for and documented within the OAM Department of a large district general hospital, targeting interventions towards mitigating barriers faced in sensory assessment.

Methods and Intervention

Baseline and post-intervention documentation of sensory impairment was collected from admission and bedside notes of 23 inpatients during each cycle. A multidisciplinary focus group of medical, nursing and practice education facilitators identified a marked underutilisation of bedside alert signs (4%), prompting creation of a redesigned bedside poster with a greater focus on sensory aid functionality.

Results

60% of posters were utilised 10 days after introduction, with an increase from 4% to 36% in recording of known sensory impairment being observed. 100% and 25% of inpatients with correctly functioning hearing aids and spectacles were documented respectively. 100% of patients admitted through frailty intervention streams were assessed for sensory loss, compared to 0% admitted via the unselected medical take.

Conclusions

Improved bedside alert posters provided initial evidence as a sustainable improvement in supporting inpatients with sensory impairment. Incorporating positive lessons from frailty team practice will assist in developing future education sessions, highlighting intended sign usage and transferrable sensory assessment methods for involved healthcare teams.

References

1. Hearing Matters. Action on Hearing Loss. 2015. Available at: https://shorturl.at/tBEST [Accessed: 23 Nov 2023].

2. Healthy Ageing Evidence Review. 2011. Age UK, N.D. Available at: https://shorturl.at/fqAOW [Accessed: 11 Nov 2023].

3. Emond et al., 2015. The current health of the signing Deaf community in the UK compared with the general population: a cross sectional study. BMJ Open 2015.

4. Vos, T et al., 2015. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet. Vol. 386 (9995) pp. 743–800.

5. Prevalence estimates provided by Professor A C Davis, using prevalence from Davis (1995) Hearing in Adults, updated with ONS (2014) National Population Projections. Available at: http://www.ons.gov.uk/ons/rel/npp/national-population-projections/2014-… [Accessed: 11 Nov 2023].

Background & Introduction

In response to the recent publication of the new British Geriatrics Society undergraduate medical curriculum (1), the medical education department at Glasgow Royal Infirmary created a session focussing on frailty for undergraduate medical students. The aim of the session was to introduce the concept to students by exploring and expanding on their experiences of frailty on placement. 

Methods - The session 

We used a pedagogical approach in a short, 90 minute session for small groups of students. The session was split into three activities; the first activity was a case of an older adult presenting acutely with urosepsis. The session dealt with acute treatment for frail patients including polypharmacy, collateral history taking, and consideration of patients wishes and advanced directives. The second activity presented the students with three patients with differing manifestations of frailty; students  were then asked to discuss the concept of ‘the dying process’, and how they would need to support each patient in differing ways. Finally, students were given a ‘frailty suit’ which included “visual impairment glasses” and “reduced dexterity gloves” then asked to complete several activities of daily living. This light hearted activity allowed students to experience then reflect upon the effects of frailty.

Results

The session was delivered to 25 students, of which 16 provided feedback.  Over 85% of students stated that the session was extremely relevant and well delivered on a Lirkart scale; comments included “...we don’t get taught about it enough in medicine”.  Results highlight that students recognise the utility of frailty focussed sessions in medical education.

Conclusions

We show that students are aware of the gap in frailty curriculum and an interactive discussion focussed session is one way to enhance their understanding of frailty. We present details of the session, and further iterations of the project we hope to introduce during the upcoming academic year. 

References

1. Grace M E Pearson et al, Age and Ageing, 2023, Volume 52, 1-8  

Introduction :

This study demonstrates how a network of geriatric medicine trainee representatives was established across the UK. The intention of the network was threefold: accurately represent the interests of trainees by gathering national feedback, develop a job description of deanery trainee representatives and create a community of practice between representatives.

Method:

Deanery trainee representatives were identified through TPDs then contacted to participate in an online questionnaire which also consented for whatsapp group invitation.

Results:

Deanery representatives were identified for 12 out of 13 deaneries, the final post was vacant. The survey response rate was 83% and all respondents gave permission to be added to the whatsapp group. We gathered information regarding eligibility, appointment and the role of deanery trainee representatives. Most deaneries (73%) do not require representatives to be a minimum grade whereas 27% required representatives to be ST4 or above. Over half (55%) were appointed following an expression of interest without an election, 27% required an election and 9% were approach and appointed directly either by the TPD or current representative. Once appointed 82% had no fixed term whilst 18% would have a term limited to two years. Once appointed the role entails an invitation to the local higher specialty training committee for 73% of respondents and 73% also reported a role in organising regional training.

Conclusions :

The aim of this project to create a network between deanery representatives has been achieved and produced an engaged network of representatives facilitating accurate representation of trainees at a national level. Further applications include collaboration between trainees to share training practices. In a period of training recovery following the Covid-19 pandemic and a new geriatric medicine curriculum a community of practice between trainee representatives has enormous potential to improve training quality and experiences for geriatric medicine trainees in the UK.

Aims

This closed loop audit aims to primarily assess and improve the number of geriatric patients who fell on elderly wards in a District General Hospital using cost effective methods. The secondary aim is to improve documentation of falls and assess for contributing factors. Hypothesis The primary hypothesis is that number of falls can be reduced through better nursing training and co-locating high risk patients. The secondary hypothesis is that improvements in documentation can be made with nursing training specified to falls and to corroborate risk factors with existing literature.

Methods

The first cycle was conducted between February 2021 to May 2021. Patients who were deemed high risk of falls, defined as over 80 years with at least 1 previous fall, were co-located. Nursing staff were provided with falls related training and how to report falls. The audit was repeated between the months of February 2022 and May 2022 to prevent seasonal bias. Results collected using the computerised internal patient records and paper documents. The number of falls, in addition to demographics, comorbidities, medications and complications were collected and compared.

Results

It was shown that cost- effective measures implemented in this audit significantly reduced the number of falls- down from 50 to 29 total falls across the same time period. We showed polypharmacy is a contributing factor to increased falls, with anti- hypertensive medications recurring as a repeated offender. 90% of those who fell were recurrent fallers, highlighting the importance of early identification of those at high risk.

Conclusion and further studies

This audit has highlighted the importance of simple, clinically effective and cost- effective measures in falls prevention. Further improvements, such as falls alarm for patients and refurbishing of ward layouts have been suggested by nursing feedback. Once implemented, the wards can be re- audited for further falls prevention.

Introduction:

Delirium is a common presentation in older people and associated with falls risk, longer inpatient stay, post-discharge institutionalisation, accelerated cognitive decline and higher mortality. While median duration of delirium is reported as 1 week but for one third patients, symptoms may persist 3 months or more, even a proportion of patients will never fully recover to their pre-delirium cognitive baseline.  It is essential we are sharing the diagnosis with people and their relatives in order to provide information, facilitate discussions around the risks of hospital versus home, reduce distress and highlight the role that carers play in delirium management. Physicians should be aware that delirium sufferers often have an awareness of their experience and for affected person and their family, delirium can be a cause of significant distress. Identification of risk factors, education, and a systematic approach to management can improve the outcome and experience of the syndrome [1].

Aim: To provide delirium education and Improve documentation up to 95 % in GAU.

Methodology:

• Prospective data collection.
• Jan 2023 to March 2023.
• Monthly data analysis of 20 patients in GAU with the confirmed diagnosis of delirium.

• PDSA 1 Departmental teaching and SIGN delirium leaflet awareness and availability .
• PDSA 2 Poster as Visual prompt.

Results:

 After 2 PDSA cycles, we noticed significant improvement in delirium education and documentation up to 95%.  A further Qi project is ongoing to embed the TIME bundle within our daily practices which will hopefully ensure that this improvement is sustained by giving another prompt to discuss and document diagnosis. 

Conclusion:

 Along with prompt diagnosis and management, good educational approach and clear documentation will lead to improve understanding about delirium, reduce distress and facilitate safe early discharge.

Reference

Healthcare Improvement Scotland SIGN

Risk reduction and management of delirium

March 2019

Introduction: A weekly ward-based teaching programme was designed and implemented using quality improvement methodology. 10 topics were identified to be covered during each 4-month rotation. 1) Topic of the week introduced via a presentation in the weekly teaching session; 2) Daily topic discussions at ward level.

Method: 7 wards. PDSA 1 (weeks 1 and 2): Weekly poster with the topic and a daily fact / question PDSA 2 (week 3 onwards): a) Software introduced to enable interaction in the teaching session b) Departmental WhatsApp used to send out daily questions. PDSA 3: a) New topics selected b) More staff groups added to WhatsApp group c) Questions weekly for each ward to ‘answer’ in the WhatsApp group

Results: Cycle 1 – little daily ward level discussion. Generating discussion in weekly teaching difficult. Cycle 2 - more engagement with both discussions. Variation in (MDT)staff group awareness. Daily teaching not habitual everywhere. Nursing staff more engaged with prompt cards than via Whatsapp. It was clear that each ward should be supported to have a different approach to delivering the teaching. Not all staff could access to weekly teaching sessions. Cycle 3 – more ward level ownership and interaction in the virtual space. The wards that have gained the most benefit from the teaching have made the questions a fixed part within their morning routine and include the entire MDT in five-minute discussion around the questions.

Conclusion: Staff working in these wards were generally positive about the weekly topic style. Having clinical leaders who are invested in teaching can support daily - cooperation and “buy-in” from those in senior roles is crucial for the development of this learning culture. This work has demonstrated some of the challenges of teaching a diverse multidisciplinary team to make information and learning accessible and useful for all.

Improving the quality of teaching for junior Doctors within the Ageing and Complex Medicine Department; introducing a novel teaching and training programme. 

Introduction 

Feedback from the National Training Survey (NTS) in 2018 showed suboptimal satisfaction levels within our department, particularly for local teaching and clinical supervision. A novel dedicated teaching and training programme was designed and implemented. National and local feedback from trainees highlights significant improvement in satisfaction levels across all domains.   

Method 

The new programme includes scheduled weekly teaching using a defined geriatrics curriculum; simulation sessions, improved opportunities for bedside teaching and workplace-based assessment, opportunities to present patients/interesting topics at weekly teaching, overhaul of our induction programme, support and supervision with QIPs/research including formal end of placement QIP presentation sessions. We reviewed national feedback alongside our own locally sourced feedback to quantify improvements in satisfaction levels and address further areas for improvement.  

Results 

Feedback from the NTS shows satisfaction within all domains has improved between 2018 and 2022. In particular, satisfaction with clinical supervision improved from 80.1 (below national average) to 88.33, satisfaction with our induction process improved from 75.19 to 88.89 (above national average) and satisfaction with local teaching improved from 70.83 to 81 (above national average). Local feedback showed that trainees are satisfied with the quantity and quality of teaching and training during their placement; 92.5% rated the quality of clinical supervision as very high or high quality, 95% felt the formal teaching was useful to their learning, and 90% would recommend an ACM placement at RAEI to their colleagues.  

Conclusion(s). 

Our teaching and training programme has improved the quality and quantity of learning experiences for junior doctors within our department. There are domains in which satisfaction remains suboptimal including “rota design” and “workload” however there are factors affecting these areas which are out of the control of our department and therefore may present challenges when trying to implement change.  

Introduction

Training in the subspecialty of Movement Disorders (MD) has been previously identified to be lacking in geriatric medicine, through a survey in Northern and Yorkshire regions (2006). In anticipation of the new geriatric medicine curriculum, the MD Special Interest Group Committee of the British Geriatric Society (BGS) sought to evaluate current experiences of training and perspectives of trainees for their subspecialty training.

Method

An online survey was designed by trainees with input from supervisory clinicians. Alongside demographic details, a combination of multiple choice and open questions were included to explore experiences, barriers and ideas for improvement for MD training. The impact of the Covid-19 pandemic was included within response options. The survey was circulated by email to all trainees within the BGS September 2021, with a one-month response window.

Results

Number of respondents was low (n=25) but included all years of training and diverse regions. 12% intend to specialise in movement disorders and 24% were working in posts with a specific MD component. Satisfaction with movement disorders training was low with none reporting complete satisfaction and more than half being dissatisfied. Clinic experience varied greatly, but was frequently perceived to be insufficient. Exposure to advanced therapies was rare. Course attendance, QIP or research, and delivery of teaching within MD were all infrequent. Whilst Covid-19 was a barrier to MD clinics and courses for half of all respondents, further factors included limited clinic capacity (46%), no training clinics (33%) and no local MD services (29%). The most significant barrier to accessing advanced therapies experience was lack of local provision (79%). Finding a suitable course, cost and ability to take study leave restricted course attendance.

Conclusions

The identification of areas of deficit, barriers to training and suggestions from trainees could help to improve training and aid implementation of the new curriculum.

Introduction

Despite recognition of the status of gerontological nursing as a speciality , there is no specific UK competency framework for early career nurses working with older people. As part of a feasibility intervention to improve recruitment and retention of nurses within the speciality (ECHO Early Careers in Healthcare of Older People and PEACH Programme for early careers for care home nurses) , we developed a bespoke competency framework appropriate for nurse working within all sectors.

Method

The national and international literature on published competency frameworks was reviewed to identify core domains of knowledge and skill. We integrated these within a CGA model to develop a draft competency framework which we then tested for face and content validity. It was reviewed by expert practitioners and managers from NHS and care home providers, and a national reference group (British Geriatrics Society Nurse Special interest group). It was then implemented by students under taking the ECHO and PEACH programmes. A mixed-methods approach was used involving online surveys, one-to-one interviews and focus group interviews with students, mentors, ward managers and care home managers. Ethical approval was obtained from the university ethics committee

Results

From an initial draft of 80 competency statements 69 were adopted across 10 domains. Thirty students across the ECHO and PEACH programmes used the framework and participated in evaluation. Our analysis found that students benefited from recognising unique gerontological knowledge, expanded insights into practice and affirmation through mentor feedback. Some students faced logistical challenges including access to mentors. The framework was found to be appropriate and acceptable across both hospital, community and care home settings

Conclusion(s)

The competency framework was valid in clinical gerontological settings across hospital, community and care homes, and supported knowledge and skills development and evidencing for early career nurses.

INTRODUCTION Falls have significant morbidity and mortality in Nursing Home (NH) residents. By improving education to NH staff we aim to reduce 999 calls and associated adverse outcomes. . NH residents are more likely to fall than people living in the community and are more at risk of further falls as interventions and risk factor modification is more difficult.

METHODS Phase 1 - Ambulance calls, where a vehicle attended the scene, between 01/01/2020-28/02/2022 from NH in Swansea Bay University Health Board (SBUHB) concerning Falls/?Falls (Haemorrhage/lacerations, Unconscious/fainting, traumatic injuries, sick person, convulsions/fitting) were analysed and survey was sent out to all NH. Phase 2 - Education was provided about CWTCH (hug in Welsh) and staff were surveyed post intervention Can you move them, Will it harm them? - new neck/back pain, anticoagulation, Treat them – analgesia, wound-care, Cup of Tea – can eat & drink , Help – when contact 999.

RESULTS Phase 1 – Between 01/01/2020-28/02/2022 4907 calls, 866 were falls (17.65%) and 1032 ?Falls (21.07%), 60.49% conveyed to hospital. 47% of NH do not have falls guidelines and 100% patients are Nil by Mouth and 88.24% are not moved. Emergency services were contacted 88.24%. Phase 2 - Education was delivered to all NH in Swansea (122 staff). Feedback showed 100% feel more confident in giving food and drink, moving patients with 90.98% less likely to contact 999 and 75.40% not having previous training with 96.72 % more confident in giving analgesia.

CONCLUSIONS Falls remain a significant burden and a rapid service would improve care with conveyance reduction to 53.1% post education (60.55% pre-education). Future directions include offering this education to NH in Neath/Port Talbot. From March 2022, we offer same-day assessment for NH residents (and others) from primary care and ambulances and are developing a PRN analgesia pathway e.g.PENTHROX