Improving service delivery

Pulmonary embolism (PE) is the third most common among acute cardiovascular diseases, after myocardial infarction and stroke, with a significant mortality rate. At Portsmouth University Hospital's acute medical and respiratory departments, inadequate understanding of pulmonary embolism diagnosis and management, which led to unnecessary investigations and medications putting the patients at risk of the side effects and complications of that, was the main impetus for initiating this audit. The hospital did not adhere to the NICE recommendation of regular interim anticoagulation for patients awaiting imaging for probable PE. A significant number of patients unnecessarily admitted to the hospital due to PE could have benefited from outpatient treatment. We collected data for eight weeks both before and after the implementation of the new hospital PE pathway, following a baseline audit and PDSA-based problem-solving, which underscores the significance of accurately utilising the Wells Score and PE rule out criteria (PERC). We obtained PE diagnosis criteria from NICE standards for comparison. The new hospital PE pathway was a result of the initial audit. The results from the re-audit showed an improvement in documentation and calculation of the Wells score from 16.1% to 66.1%, the PERC score from 9.1% to 58.3%, and the PE severity index (sPESI) score increased from 9.1% to 58.3%, as well as an increase in the number of junior doctors who initiated the PE pathway from 19.6% to 41.9%. Additionally, the proportion of inappropriately requested investigations, such as D-dimer and CTPA, was reduced. Also, the number of CTPAs requested in line with the guidelines increased from 11.11% to 52.27%, and the diagnostic yield of PE on CTPAs increased from 36.08% to 64.85%. A simple diagnostic pathway resulted in a decrease in unnecessary investigations and an increase in the diagnostic yield of PE.

Introduction

At Epsom and St Helier, a dedicated Frailty service exists during daytime hours, and not weekends, nights or Bank Holidays. During these hours, patients are reviewed primarily by a cohort of “frailty-naïve” medical junior doctors. We aimed to compare the management plans, patient outcomes, rates of discharge, documentation and care delivered by medical junior doctors to that of an established frailty service.

Methodology

Data on presenting complaint, demographics, degree of frailty, postcode was collected on all patients over the age of 65, presenting to A&E at Epsom and St Helier Hospitals with a Frailty Syndrome. Patients who presented with symptoms or signs outside of the frailty syndrome criteria were excluded. The Medical Service was compared to the Frailty Service on rates of discharged and whether or not a resuscitation status, an escalation plan, baseline functional assessment, vision and hearing assessment, home set-up assessment, cognitive status, the elicitation of patient preferences and a medication assessment were performed.

Results

In 202 patients, average age was 85.2 years and consisted of 85 men and 117 women. Unwitnessed falls were responsible for 143 presentations. 127 patients were Caucasian and from the least deprived deciles. 109 patients (54%%) were seen directly by Frailty, and another 93 (46%) seen as referrals to the Medical Doctors. 33(16%) of patients were discharged by Frailty within 24 hours of admission, compared to 15(7.4%) by the Medical Team. The Frailty Service was more proficient in assessing patient baseline status (OR1.71), property (OR1.64), cognition (OR1.43), medications (OR1.28) and patient preferences (OR21.95).

Conclusion

Frailty reviews at an early stage in patient presentation to hospital was twice as likely to result in discharge within 24 hours of admission. Additionally, patients were more likely to have a thorough, comprehensive frailty assessment, and were significantly more likely to be empowered in their decision-making process.

Introduction-

Treatment Escalation Plans (TEPs) and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms are vital in hospital care, providing clarity on patient management while considering patient wishes. Though DNACPR decisions ultimately lie with doctors, discussions with patients or relatives foster understanding. Factors such as comorbidities and the Clinical Frailty Scale (CFS) influence these decisions. Proper form completion guides patient care and helps prevent adverse outcomes, but incomplete forms often lead to challenges for medical teams.

Objective- 

This quality improvement project aimed to educate doctors on completing these forms to improve patient care.

Method-

Data were collected on TEP and DNACPR form completion across hospital wards, focusing on CFS, comorbidities, consultant approval, and patient/family involvement. Teaching sessions and educational leaflets were provided to doctors to enhance understanding. Post-intervention data were collected and analysed.

Results-

Two audit cycles were completed: the first with 156 patients, the second with 129. Compliance to Consultant approved DNACPR form completion increased by 9% (from 79% to 88%). Patient and family involvement in DNACPR decisions improved by 2% (from 84% to 86%). Documentation of comorbidities increased by 6% (from 20% to 26%), and CFS documentation improved by 5% (from 13% to 18%), though overall levels remained low.

Conclusions-

The interventions improved doctors' understanding of the importance of completing TEP and DNACPR forms, rationalising patient's care.The study highlights the crucial role of these forms in managing hospitalised patients and providing timely, appropriate care.Continued education through teaching and informational leaflets is essential for better patient outcomes.

Introduction

Board round is essential in geriatric care for clinical prioritisation, planning discharges and identifying any barriers to discharge. This process can be limited by poor handover, lack of roles and a defined structure. This project aimed to improve board round efficiency in an inpatient acute frailty setting.

Methods

The project involved a 2 stage PDSA cycle including data collection at baseline and after each successive intervention.

Stage 1: Role allocation and Board round proforma

Stage 2: Doctor education

Data related to several outcomes was collected retrospectively over 4-5 days per cycle. Inclusion criteria included all inpatients on the acute frailty unit at the time of each daily morning board round. Qualitative data was collected at baseline and after cycle 1.

Results

Improvement was shown in all outcomes after two cycles:

• Board round length (<30 minutes)
• Principal problem listed correctly (33% to 76%)
• Medically fit patients marked correctly (57% to 83%)
• Time since problem list last reviewed (11 days to 1.9 days)
• Proforma completed (89%)
• Proforma visible in the patient notes (68%)

Conclusion

This project demonstrated improvement in terms of accuracy and efficiency to the board round process. This has implications for geriatric patient care and flow.

The format has been rolled out to other medical wards across the trust helping to standardise the board round process.

A further intervention of a ‘Smartphrase’ and teaching sessions to facilitate updating the problem list has been implemented with further data collection planned.

Introduction: Our aim is to improve clinical efficiency by reducing avoidable discharge delays, increased number of discharges and availability of specialist Frailty beds. We intend to undertake 8 PDSA cycles with a new idea.

Background: 23 bedded Acute Frailty Short Stay Unit (AFU). Patient group defined as those admitted to the unit from April ’24 to current. Our initial spot-audit analysed 18 patients; the mean total avoidable delay was 31.52 hours (range 4.73- 123.3 hours). Initial analysis demonstrated that delays became longer throughout the course of the day. Methods: We evaluated staff opinions on the discharge process with a survey. Outcome measure identified as number of weekly discharges and appropriate patient flow to the AFU. Balancing measure identified as number of readmissions within 48 hours. PDSA cycle 1 allocated a doctor to write discharge letters during MDT. PDSA cycle 2 allocated a suitcase symbol to a potential discharge in the next 24 hours. We then adapted the suitcase with colours to differentiate between ready and awaiting investigations/ aim home in 24 hours. The next involved allocating a discharge doctor to review patients with an amber suitcase from the previous day first.

Results: Initial staff feedback has been positive. Data demonstrated an increase from the baseline (from below 20 to an average of 25 discharges a week). This then dipped throughout May, during which time there was an unusual level of escalation, staff absences and annual leave. The data has begun to recover to a high of 27 discharges in the week of the start of June.

Conclusions Utilising the MDT has been vital in the sustainability of the project. On-going staff surveys and regular meetings will help to ensure sustainability. Ongoing focus and further cycles are on encouraging junior members of the team to be involved with the intervention.

Introduction

Physical and cognitive frailty combined with unfamiliar surroundings in hospitals puts elderly patients at high risk of falls. It has been demonstrated that patient-centred, non-clinical stimulating activities in hospital have been found to reduce agitation, improve affect and engagement, relieve pressure on nursing staff and reduce falls. In the Medicine of the Elderly (MOE) wards of an urban teaching hospital, after a successful pilot, a Meaningful Activity Team (MAT) was implemented. The effect of this change to patient and staff well-being was assessed, as was the frequency of falls on the wards.

Methods

The MAT was implemented by July 2023. In November 2023, questionnaires were distributed to staff across the MOE department to collect quantitative (Likert scales) and qualitative data on potential benefits and limitations. As part of our Quality Programme, prevalence of patients admitted to MOE wards with a diagnosis of dementia/delirium is regularly measured, as are patient falls, which are recorded via DATIX and collated on ward-based run charts. We interrogated these charts for any significant changes.

Results

The current prevalence of patients with delirium/dementia across the MOE 152 bed footprint is 69%. 49 staff questionnaires were completed, 47 of which had comments. 100% of respondents agreed or strongly agreed that the MAT benefited patient well-being. 87.8% agreed or strongly agreed that the MAT benefited staff well-being (figures 1, 2). Common themes regarding patient well-being were patients being happier, brighter and more sociable. Common themes regarding staff well-being included less stress and increased time for clinical tasks. The frequency of falls has reduced with some wards seeing maintained shifts in median number.

Conclusion

Implementation of the MAT across our MOE wards has improved patient and staff well-being. Reductions noted in frequency of falls have been maintained.

Introduction: Within our ward multidisciplinary team (MDT) meetings we noted that there was often a lack of attendance from key disciplines, inconsistent content, and an overly medical emphasis. We wished to create an MDT that was structured, with consistent input from nursing and therapy teams, covering components of comprehensive geriatric assessment (CGA).

Methods: On one pilot ward, we agreed a new structure to MDT meetings. Clinical leadership was required to facilitate staff sharing their observations, with clinicians speaking less. We used an A0 poster as a clear visual prompt for maintaining structure. A survey on teamworking and safety was performed on the pilot ward by the Improvement Academy. We had several iterations, but a standardised structure with key ingredients for MDTs was rolled out across five other Elderly Medicine wards. A further survey was performed examining opinions on quality of MDT working.

Results: After our interventions, CFS, 4AT and mobility went from being discussed 0% of the time in July 2021 to 100% of the time on the pilot ward between January and July 2024. Mobility went from being discussed from 0% in July 2021 to 71% in May 2024 across all wards. 90.5% of the pilot team thought that decision making utilised input from relevant team members. In a further survey in May 2024, 82.6% agreed that the relevant team members opinions were listened to.

Conclusion: A structured MDT process was successful in incorporating key elements of CGA whilst improving MDT teamworking. Starting with a single ward allowed others to gain confidence in the success of the process and enable natural spread. Key stakeholders including organisational leads were consulted and involved in improvement work, such that this is now a standard way of working. The lessons learned are being used to contribute to a digital dashboard tracking MDT progress.

In 2022 we had a unique opportunity to develop a Geriatric service in Totnes Community Hospital after a long-standing GP led service provision ended. Given the fact that the majority of patients in the Community Hospitals were over the age of 65 and many had multiple co-morbidities or presented with a frailty syndrome, it was felt that the Geriatric department was the most suitable specialty to take over the service provision. Method Over a period of 12 months, we have gradually introduced key aspects from the Comprehensive Geriatric Assessment (CGA) to the care of our patients. Every new patient had a CGA on admission, completed by the clerking doctor with support from the MDT. We have concentrated on identifying and managing falls risk, bowel and bladder care, bone protection assessment and reviewing inappropriate polypharmacy. Through collaboration with our community pharmacist and nursing staff we have introduced additional medication administration services to include intravenous bisphosphonates, monofer infusions, medical hyperkalaemia management and intravenous electrolyte replacements. For our frailer patients we looked at prioritising care in the community, and closer to their home and family. Where appropriate and safe, we kept the patients in the community hospital for both acute illness and end-of-life care, instead of re-admitting them back to the acute hospital. Conclusion Over the year we have trained, upskilled and supported our nursing staff in managing and treating more acutely unwell and complex patients, so that we can provide more comprehensive and holistic care to our frailer patients in a community setting. We have prevented numerous re-admissions back to the acute hospital by being able to provide increased level of medical care. This was particularly important for the many patients with advanced dementia and delirium. The current model of care is still ongoing and continuing to develop.

Introduction 

Prompted by observation and directed by The Centre for Perioperative Care (CPOC) guidelines, two quality improvement cycles were carried out during 2021-2023 seeking to improve the identification and care of frail patients admitted emergently to the general surgery department at Peterborough City Hospital (PCH), a busy district general hospital with over 40 general surgical beds. 

Method 

Two Plan-Do-Study-Act cycles were undertaken. The medical records of patients 65+ years were interrogated for documentation of frailty assessment, evidence of escalation planning and geriatrician review. Results were presented at departmental clinical governance meetings where the barriers that are limiting progress in this area of clinical practice were debated. In view of finite resources and funding, realistic measures, such as highlighting frailty scores during handover, were introduced during both cycles. 

Results 

Both cycles demonstrated that current practice within the general surgery department at PCH does not meet CPOC standards and no significant improvement was made by simple interventions. Frailty scores are not routinely assessed or utilised by clinicians, only some patients are given opportunity to undertake shared decision-making including escalation planning and a small number of patients receive a geriatrician review. Departmental discussions revealed barriers including lack of knowledge of frailty, insufficient communication within the department, and insufficient resources for specialist geriatric input. 

Conclusion 

This project has demonstrated the challenges of changing clinical practice on the front line. Although our results demonstrated no significant improvement in care of frail surgical patients, change has occurred in terms of engagement of general surgeons. Gold standard practice seems elusive, but small, realistic steps are being taken. Whilst there is no immediate prospect of the resources to deliver specialist geriatric input for all frail surgical patients, there is hope that progress can be made towards this so we will continue to build a case for future investment. 

Introduction

Introduction of the medical examiner (ME) service has changed the process in which the Medical Certificate of Cause of Death (MCCD) is completed across South Wales. In a tertiary hospital we endeavoured to improve team ownership of medical cause of death decisions, senior involvement, and communication of this to the medical examiner service, through development of a new process and communication form.

Methods

Two PDSA cycles have been completed. With stakeholder involvement we produced a process map and developed a Proposed Cause of Death form. In 2022 medical teams on 2 wards (A&B) trialled a new process - to discuss as near as possible after death the likely cause of death and submit a Proposed Cause of Death form. We collected data on number of deaths, number of forms completed and time between death and MCCD completion. In 2023 a task and finish group developed an electronic form and piloted on a further three selected medical wards (C,D&E).

Results

Cycle 1: Mar-Aug 2022. Proportion of deaths with form completed: Ward A 0%(0/25), Ward B 71%(27/38). Time from death to MCCD completion was not increased by form implementation (3.1 days after vs 4.7 days before). Cycle 2: Aug 2023–Jan 2024. Proportion of deaths with form completed: Ward C 60.9%(14/23), Ward D 0%(0/22), Ward E 5.3%(1/19). Time from death to MCCD completion increased by only 0.6days compared to 3 control wards (5.7days vs 5.1days).

Conclusions

The process and form were successfully adopted on 2/5 wards. Facilitators of adoption were ward level consultant engagement and prompting of the medical team by the bereavement team. Barriers to adoption were a perception of extra work and being unable to perceive usefulness of the process. Ongoing work aims to improve team motivation through education and recruitment of ward 'champions', and rollout to additional wards.