Improving service delivery

Introduction

In 2021, the Welsh Government launched the “All Wales Dementia Care Pathway of Standards”, which the Cardiff and Vale University Health Board (CVUHB) Memory Assessment Service (MAS) works under (1. Welsh Government, 2021). This service evaluation aims to evaluate the CVUHB MAS diagnostic pathway against these standards.

Method

This retrospective review analysed 299 referrals to the CVUHB MAS from August 2020-2023. Data was collected via referral and clinic letters, focusing on demographics, referral sources, diagnostic timelines and clinical outcomes.

Results

Patients had a mean age of 78.2 years (n=299), with 86.0% (n=257/299) referred by General Practitioners. The average Charlson Comorbidity Index (CCI) was 4.93 (n=299) and the median Clinical Frailty Scale (CFS) score was 4 (n=299). Patients were on an average of 6.5 (n=299) medications at referral, with an anticholinergic burden (ACB) score of 1.12 (n=293) and 15.0% (n=44/293) had a high ACB (≥3). The average time from referral to diagnosis was 19.3 weeks, primarily due to pending neuroimaging. Ethnic minorities experienced longer symptom onset to diagnosis, 2.56 (n=16) vs 1.94 (n=263) years average. 59.2% (n=177/299) of patients received a diagnosis of dementia and 36.5% (n=109/299) of cognitive impairment. Medication was initiated in 30.8% (n=92/299). 84.1% (n=244/290) required one clinical appointment to receive a diagnosis.

Conclusions

Results showed the average CCI score was 4.93, indicating significant health burdens. The need for targeted medication reviews in Memory Clinic was highlighted in 15.0% of patients with an ACB ≥3. Addressing ethnic disparities is crucial to the overall reduction of diagnosis times. The CVUHB MAS achieved a high diagnostic rate at first clinical contact (84.1%). 30.4% (n=91/299) received a diagnosis of mild cognitive impairment, a critical cohort for early intervention to manage disease progression. Streamlining the pre-diagnostic pathway, especially performing neuroimaging at referral, is essential to meet the 12-week diagnosis target (1).

Introduction:

Population is growing old worldwide and UK is no exception. Health service models designed to cater the needs of service users are under immense pressure due to the aging phenomenon. With unprecedented demand, their often low acuity, hence low priority and delayed conveyance to hospital and unavailability of services to address their needs due to delayed arrival; frail older patients often have to wait longer in emergency department (ED) to receive care in ED. Innovation and news models of care are therefore need of the hour to address this challenging situation.

Methods:

Quality improvement initiative to establish acute frailty service.

Development of Older Person assessment unit (OPAU) in Oct 2022 with already established and functional acute frailty team.

Plan for direct referral to OPAU from South East coast ambulance service (SECAmb) colleagues.

Weekly meetings with SECAmb.

Geriatrician of the Day supporting alternative pathways instead of ED.

Development of frailty poster with criteria to referral and uploaded on SECAmb work iPads, displayed in ambulances delivery area and ambulance queuing area inside the hospital.

Single point of access phone number launched April 2023 to access frailty team & other alternative services from outside the hospital.

SECAmb webinar for education and awareness of alternative pathways (UCR, SDEC, frailty, virtual ward), attended by 40 front line SECAMB staff.

Results:

October 2022 – 0 patients.

November 2022 – 2 patients.

December 2022 – 8 patients.

January 2023 – 18 patients.

February 2023 – 32 patients.

March 2023 – 33 patients.

April 2023 – 39 patients.

Conclusion:

With sustained efforts and effective collaboration, number of patients being referred to alternate pathway (frailty team) are increasing with anticipated significant reduction to SECAmb conveyance to ED in the long run, addressing overcrowding issues.

The commonest nosocomial infection in the UK is Hospital Acquired Pneumonia (HAP), associated with prolonged length of stay and mortality. The HAP incidence on Elderly care wards was > 5% of admissions, exceeding the national average. An initiative ‘Mind the HAP’ was launched which included doctors, nurses, pharmacists, SLTs, physiotherapists and coders to improve HAP diagnosis, management and prevention. Methods: To monitor the effectiveness of the interventions 3 audit cycles were performed between 2019 and 2023. Several interventions were implemented between 2019 - 2023.A multidisciplinary steering committee was formed with 3 work streams (diagnosis, management and prevention). To improve the accuracy of diagnosis and management of HAP, focused educational sessions were conducted for junior doctors with monthly meetings with coders. Nurses championed implementing the HAP prevention strategies i.e. hand hygiene, mouth care and positioning at 30-45 degrees. Regular comprehensive training sessions were held. HAP awareness and education campaign was launched. Daily nursing huddles helped to identify high risk patients. Physiotherapists provide chest physiotherapy to yield sputum sample collection among pneumonia patients. An electronic dashboard of incidence of HAP against the preventative measures and sputum culture reports has been launched with help from informatics. Information leaflets on HAP were created for patient awareness. An electronic HAP power plan to facilitate diagnosis and management of HAP will be launched from February 2024. Results: HAP incidence has dropped to < 2 %, diagnostic accuracy improved from 35% to 81%, and sputum collection has increased from 9% to 24%. The HAP Quality Improvement Project received first prize for the most impactful Quality Improvement initiative at the Trust-wide conference in 2023. The results have been shared with the regional Microbiologists. The collaborative efforts coupled with effective leadership and guidance, have been pivotal to the success of "Mind the HAP" project.

Introduction. The multidisciplinary assessment clinic (MDAC) is an outpatient service for older people at a district general hospital. Patients are triaged to the MDAC clinic if they have geriatric syndrome (for example falls) plus comorbidity and/or mobility, social or cognitive concerns. The service had a high ‘did not attend’ (DNA) rate compared with other geriatric outpatient clinics. This project aimed to reduce MDAC DNA rates and improve cost effectiveness through implementation of a new pre-appointment telephone service.

Method. We analysed six months of attendance data prior to establishing the pre-appointment telephone service. The existing system consisted of a standardised trust appointment letter and a text message reminder. For the new system a healthcare assistant (HCA) telephoned patients the day before their appointment to confirm attendance and discuss any concerns. We analysed six months of attendance data following the implementation of the new system and compared DNA rates.

Results. Prior to implementation of the new pre-appointment telephone service, 29 of 268 patients DNA (11%). From the second data set, following implementation of the new telephone system, 11 of 253 patients DNA (4%). Successful contact was made with 72% of those phoned, allowing confirmation or cancelled appointments to be rebooked. Chi square analysis found a significant difference between the two systems, with a p value of <.01 indicating an improvement in attendance rates with the new system.

Conclusion. Telephoning frail older patients prior to outpatient clinic appointment significantly reduces DNA – a similar system could be implemented other geriatric medicine settings.

This Quality Improvement Project (QIP) addresses the pressing need for increased awareness of delirium among patients' relatives. With a 26% rise in the elderly population in Cambridgeshire, surpassing the 18.6% national average, the project aimed to provide crucial information to enhance understanding and support for patients grappling with delirium, a condition affecting up to 50% of elderly hospital patients. This prospective study was conducted across seven geriatric wards at Cambridge University Hospital (CUH). Baseline measurements utilized existing data on CUH Delirium website views and involved collecting surveys to explore delirium awareness among total of 26 randomly selected subjects who were relatives of patients. To establish a baseline for comparison between pre- and post-intervention data, specific durations were selected in different calendar years (5/4/2022 - 18/7/2022 and 4/4/2023 - 17/7/2023). Interventions included strategically placing redesigned CUH Delirium Posters with QR codes across wards, along with awareness campaigns targeting healthcare professionals, including Dementia and Delirium Champion Training. Pre- and post-intervention questionnaires showed up to 10 -20% increment in respondents' awareness, understanding, and interest in delirium. Post-intervention, website views surged by 132%, indicating the effectiveness of the multifaceted approach. Key findings highlighted the importance of laminated posters, strategic placement based on staff feedback, and the necessity for detailed data on website visits. Future recommendations include continuous monitoring, content evaluation, and strategies to address poster removal. Suggested actions involve sustained monitoring, collecting qualitative feedback, and ongoing efforts to enhance understanding of delirium care. In conclusion, this QIP serves as a successful model for increasing delirium awareness, addressing challenges through adaptability and sustained engagement. The positive impact on awareness and website engagement sets a precedent for future healthcare quality improvement initiatives, fostering continued progress in delirium care and understanding among elderly patients and their relatives

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.

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 Cardiff and Vale Memory Team is comprised of a range of healthcare professionals who provide direct and indirect contact to coordinate the care of dementia patients. Memory link workers (MLWs) are a single point of contact for patients; they contact patient’s post-diagnosis and at 6-month intervals. Clinical Nurse Specialists (CNSs) assist patients with medical aspects of their care, including diagnostic home assessments with the support of the medical team. This evaluation aimed to establish the impact of these roles on people living with dementia and their carers.

Methods

This study is a retrospective service evaluation of 200 patients, who contacted the MLWs and CNSs between early April and mid-May (289 contacts). PARIS, Welsh Clinical Portal and written notes were used to collate information on patient demographics and each contact.

Results

The majority of patients were female (70%), the median age was 83 and Alzheimer’s was the predominant diagnosis. The greatest need identified in both MLW and CNS contacts was social care provision (39%). MLWs predominantly addressed wellbeing (n=55), CNSs had discussions surrounding medication (n=39) and physical health (n=44). The most common subjective outcome in the MLW group, was improvement in quality of life (75%); in the CNS cohort it was addressing acute medical problems (37%). Overall, the contacts were divided as follows, quality of life (50%), admission prevention (24%) and acute medical (24%).

Conclusion

The service is proactive and addresses a variety of needs; it has the potential to improve patients' quality of life and prevent admission. Both professionals were able to identify deteriorating patients and increased carer burden; additionally, patients were able to receive a diagnosis in a home setting. The service could be improved with more frequent contact, streamlined links with social services and increased liaison with mental health services to improve speed of access.

In 2021, Cardiff and Vale University Health Board’s average length of stay (LOS) in Assessment Unit (AU) for over 75-year-olds was 24.2 days, due to long waits for inpatient beds. Once admitted, 23% of patients moved wards three or more times. Patient experience scores indicated poor satisfaction levels, with nearly 50% of patients feeling their needs had not been met. Staff consensus was that the environment was unsuitable for older patients.

The implementation of an enhanced frailty service began in November 2022. This was managed by a geriatrician-led team, with support from junior doctors and Physician Associates. The provision consisted of a 6-day service for the Frailty Zone, an allocated area of 12 beds in AU, an in-reach service, and input from the therapy and nurse led Frailty Intervention Team (who specialise in admission avoidance). Thus, giving the team wider reach, and ensuring frailty input from the beginning of the patients’ journey.

Between December-March 2023, there was a 36% increase in the number of patients discharged directly from AU, in patients aged 75+. This equates to an extra 21 discharges per week. The average LOS in AU reduced by 6.9 hours. Notably, the LOS for patients under 75 remained largely unaffected during this time. The number of ward transfers for this population also reduced to 13%.

The data obtained from the frailty service led to additional service development. In July 2023, the expansion of the Frailty Zone into a 19 bed Older Persons Acute Medical Unit came into effect. Staff feedback remains positive, with boosted morale. However, there is more development needed in way of communicating with all members of staff.Expansion of the Frailty Intervention Team is being developed to provide patients who are likely to need admission access to therapy and frailty nurses.

INTRODUCTION: In order to improve resident safety and reduce hospital admissions, the ‘Optimizing Bed Height Quality Improvement Study’ aims to raise awareness among healthcare professionals about the importance of ensuring optimal bed height to prevent falls and injuries in residents and to improve bed mobility.

The parameters from a 2015 study, ‘Analysis of the Influence of Hospital Bed Height on Kinematic Parameters Associated with Patient Falls During Egress', are taken into account when using intervention techniques.

METHODS: Residents aged 65 or over falling out of bed between January and June of 2022 were used as a pre-test measure. By maintaining a hip or knee angle just above 90 degrees, keeping the resident's feet flat on the floor, and ensuring that they can easily transition from sitting to standing and vice versa, the nurse and physiotherapist assessed the resident's mobility and determined the height of the resident's bed. An illustration of the ideal height is displayed on a poster that hangs on the wall above the headboard of the bed. Nurses visit each resident's room each day to ensure that the beds were in the ideal position and record this information in the monitoring system. The data obtained during the six-month period of intervention (July to December 2022) was compared with the pre-test results.

RESULTS: Results from a six-month intervention period (July to December 2022) were compared to those from a six-month pre-intervention phase (January to June 2022) with fourteen bed falls, there was a FIFTY PERCENT decrease in bed falls.

CONCLUSION: After a six-month clinical trial, the study revealed that older adults who had bed falls and trouble getting out of their beds had lower fall rates, suggesting that stakeholders' knowledge of the ideal bed height had increased.