MDT

Introduction

Frailty is a condition with increasing prevalence in the UK and significantly impacts the lives of those affected and their families. Frailty is a condition best managed by teams of skilled multi-disciplinary health and social care professionals (HSCPs). It is therefore essential that all HSCPs working with older people living with frailty are equipped with the appropriate knowledge and attitudes to look after affected persons.

Methods

The British Geriatric Society (BGS) and NHS England (NHSE) collaborated to produce an online e-learning module to support HSCPs to provide frailty care in complex situations and lead frailty services. This module was developed in line with the NHS Skills for Health Frailty framework of core capabilities at the tier 3 level. The e-learning module was launched in October 2023 and contained 4 modules: Understanding and Communicating Frailty, Identifying Frailty, Supporting People Living with Frailty and Building Systems Fit for Frailty. This module was made available for free to BGS members.

Results

Between October 2023 and January 2023, over 4000 HSCPs registered for the online module. A wide ranges of HSCPs signed up for the module with nursing staff, advanced clinical practitioners, consultant geriatricians and physiotherapists the most commonly represented groups. 92% of those who completed the module agreed or strongly agreed that the course helped develop knowledge, understanding and confidence in frailty. 91% of those who completed the module said completion of the course would help them to further improve patient care and clinical practice. Areas identified to enhance the module further included addition of further case studies and making the resource more adaptable to all UK regions.

Conclusions

e-Learning can be an effective facilitator of frailty education for a wide range of HSCPs.

Introduction. Pharmacists have traditionally worked in primary care, in the community, and with GPs. However, the role of the clinical pharmacist in primary care is evolving and there are plans to employ more clinical pharmacists in the NHS. With an ageing UK population, there is an increase in the number of people living with multiple long-term conditions, accompanied by polypharmacy, posing numerous challenges to healthcare systems. This review investigates the evidence about the varied roles and services delivered by clinical pharmacists in primary care, capturing the perspectives of health and care professionals, older adults, and their carers.

Method. Our scoping review followed the framework for scoping reviews in accordance with the Joanna Briggs Institute (JBI) methodology. A broad search was conducted in 2023 in CINAHL, Cochrane, Medline, SCOPUS, and Web of Science. We included articles that explored the landscape of clinical pharmacy services for older people in the UK, focusing on roles and services delivered, perceptions, and experiences.

Results. A total of 23 articles was included. These shed light on the multifaceted responsibilities of clinical pharmacists for older people. Stakeholder perspectives, including healthcare professionals and care home staff, emphasise the positive outcomes of clinical pharmacist involvement, from reducing other practitioners’ workloads to improving patient safety. However, communication gaps amongst the primary care team and those living with dementia, concerns about competence, and the need for clear role definitions of clinical pharmacists emerge as challenges.

Conclusions and implications. The review enhances our understanding of the clinical pharmacist service in the UK and identifies gaps in research evidence, emphasising the need for empirical studies on the experiences of older people with cognitive impairment and those from minority ethnic backgrounds. The findings can be used for policymaking, workforce planning, and healthcare provision to improve the services for older people in the UK.

Introduction

Surgical intervention may not be appropriate in frail patients with new or recurrent bladder cancer. To ensure that their care is aligned to the principles of ‘Realistic Medicine’, we developed a structured programme of joint management between our Peri-Operative care of Older People undergoing Surgery (POPS), Anaesthetic and Urology teams. This analysis examines our experience.

Method

Patients listed for surgery and deemed to be frail at initial screening, underwent Comprehensive Geriatric Assessment, an anaesthetic review (if indicated) and surgical evaluations. Validated measures of frailty, cognition and function were used. Each patient had a joint consultation with a bladder cancer and POPS specialist. Patient details, clinical metrics were recorded prospectively on a POPS database, with clinical follow-up records maintained electronically.

Results

From a total of (approximately) 460 suspected or confirmed bladder cancer patients, 100 were reviewed in the joint POPS-bladder cancer specialist clinic between January 2017 and early January 2024. Moderate/severe frailty was noted in 55%. Only 23% of patients proceeded with their intended surgery (GA cystoscopy/TURBT/cystectomy). Most patients opted for no operative intervention instead choosing best supportive care (45%), repeat flexible cystoscopy (17%) or repeat diagnostics (14%). Over the follow up period (median 4 years), of those who opted for no operative intervention, most did not need to change from the recommended plan; 5% of patients required an emergency admission (bladder washouts only).

Conclusions

This novel joint working with POPS and bladder cancer specialists appears to be a safe, comprehensive, and patient-centred approach to the effective and efficient management of frail patients with bladder cancer. It allows various important factors to be carefully considered and balanced including frailty, patient priorities, symptom burden and tumour size/grade/number. This model of care means selected patients could avoid the burden of unnecessary procedures and surveillance.

Introduction:

The geriatric population has a high incidence of dementia, delirium and frailty meaning often these patients cannot give comprehensive histories themselves. We are left with missing pieces of the puzzle; we might not know their ‘normal’ and frequently ask: ‘Are they always like this?’.

A collateral history becomes a valuable tool, contributing to a Comprehensive Geriatric Assessment and assisting the whole MDT to make informed decisions for patient-centred care.

The primary aim of this project was to improve the quality of collateral histories taken for patients admitted to the geriatric wards, with content measured against 8 domains. A secondary aim was to encourage timely collateral histories within 48 hours of admission to the ward.

Method:

Using PDSA methodology, collateral histories were analysed before and after implementation of a poster and teaching session.

Results:

At baseline each domain was covered a mean of 40.5% of the time (range 9% - 81%). Following intervention this increased by 22% to 62.5% (range 18% - 89%), demonstrating a significant improvement (paired t-test, P<0.05).

It was already common practice to take collateral histories within 48 hours of admission to the ward (91%) which was sustained post-intervention (88%).

Conclusion:

Use of a poster as a prompt, and delivering teaching, led to more thorough collateral histories. This suggests two barriers are knowing what to ask and perceived importance; elements which could be integrated into early postgraduate education. The impact on patient care has the potential to be significant and multidimensional but further work would be needed to understand this.

Introduction:

Malnutrition is a significant problem in the hospitalised population, particularly in those with cognitive impairment. Malnutrition has been shown to increase rates of infection, pressure sores, length of stay, readmission and morbidity. Malnutrition Universal Screening Tool (MUST) scoring identifies adults at risk of malnutrition and prompts dietetic referrals where appropriate. MUST score recordings across four Complex Medicine Units in the John Radcliffe Hospital were often inaccurate or incomplete, impacting on the identification of malnutrition and timely referral to dietetics. Multi-disciplinary teaching on MUST scores improved identification of malnutrition in this patient population. Further interventions are planned.

Methods:

Electronic patient records for patients >/=75 years of age admitted to the Complex Medical Units at the John Radcliffe Hospital with a diagnosis of cognitive impairment were analysed. The percentage of patients who had either an incomplete or incorrect MUST score were identified. The percentage of patients that did not receive a referral to dietetics due to an underestimated MUST score and the reasons for the underestimation, were determined. Multi-disciplinary teaching interventions focussing on the identification of malnutrition in inpatients were implemented. MUST score recording was re-analysed following intervention.

Results:

71% of MUST scores underestimated risk of malnutrition. 67% of this cohort met criteria for referral to dietetics based on a corrected score, with only 33% of this group receiving the appropriate referral. Failure to identify weight loss in the preceding 3-6 months accounted for 88% of inaccurate scores. Multi-disciplinary teaching interventions improved MUST score accuracy by 14%, indicating improved identification of malnutrition risk.

Conclusion:

Identification of malnutrition is important to improve patient outcomes. Changes to practise will include multi-disciplinary education, improved use of technology to generate accurate MUST scores and the utilisation of transfer boards with integrated weighing scales to ensure all new admissions have an accurate weight.

1. INTRODUCTION: Older adults, particularly those with multi-morbidity, frailty or cognitive impairment, are under-represented in clinical research studies. To facilitate inclusive research for this population requires empowerment of all members of the multi-disciplinary team to promote and advocate for this underserved population. However, understanding of the personal and organisational barriers to staff engagement with research within Elderly Care remains limited.

2. METHOD: Using an amended version of the research capacity and culture tool an anonymous online survey open all staff members of an Elderly Care Department (n=351) in a District General Hospital was undertaken. The survey results were used to inform the departmental 5-year research strategy and launch a multifaceted educational and engagement programme.

3. RESULTS: 107 responses to the survey were received with a wide multi-disciplinary contribution. Despite 89% of respondents stating research was not part of their job, 96% were willing to be more involved in research. Motivators to staff engagement in research included: dedicated time for research (74%), research skills training (73%), mentors (67%), research relevant to elderly care (62%), hearing from researchers within the department (54%) and local promotion of research studies (49%). Barriers to research included: lack of time (78%), unsure of opportunities (65%) and lack of skills (47%). As a result of the survey numerous departmental interventions have been staged: a multi-disciplinary research half day, research opportunity display boards, monthly departmental presentations, promotion of the associate Principal Investigator scheme, Q&A webinars and a section in quarterly newsletter.

4. CONCLUSION(S): Multi-disciplinary staff working within Elderly Care can be motivated to advocate and engage with research opportunities for older adults. Supporting their engagement through the provision of dedicated time, research skills training and promotion of opportunities is key.

East Kent has 38,101 people over 80 years, 39, 021 living with moderate or severe frailty and 304 care homes. This population have high levels of unplanned admissions which can put them at risk of long hospital stays, reduced mobility and increased delirium.

East Kent Ambulance services (SECAMB), Acute hospitals (EKHUFT) and Community Services (KCHFT) have piloted a single-point of access consisting of an ED consultant, community frailty clinician, Urgent care senior nurse, advanced paramedic practitioners. They sit together at the ambulance bases, 10am-6pm Monday to Fridays. This team reviews all patients awaiting ambulances to assess whether there are alternative services to ED which would meet the individuals' needs.

Method

The MDT assesses all patients listed as awaiting an emergency ambulance. Clinical records can be accessed from all services including GP records. If patients would benefit from treatment by alternative services, rather than conveyance, the paramedics are asked to call the MDT. This allows clinical assessment, history and investigation results to be taken into account in planning care. Patients and Carers are involved in deciding how they would like to receive medical care via a video or phone link with clinicians.

Results

Conveyance to hospital pre pilot - 62% post pilot less than 50%

Ashford catchment: admissions save weekly 27.3, bed days saved weekly 179.2

Thanet Catchment: admissions saved weekly 19.1, bed days save weekly 106.9

Conclusion

Many people can be treated effectively without conveyance to hospital through pre-hospital triage, consultation and planning by senior clinicians in a multi-disciplinary team.

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.

Background

This clinical improvement project took place at a community frailty clinic. The primary and secondary care collaboration clinic comprised of an MDT including a physiotherapist, HCA, social prescriber, consultant geriatrician and GPwER in frailty. Older adults with a Rockwood score of 5 or more were assessed using the CGA domains. 

Introduction

Anticholinergic burden (ACB) is defined as the cumulative effect of taking one or more medications with anticholinergic effects (e.g. opioids, antimuscarinics and trycyclics). ACB score is a method of quantifying this. Higher ACB scores (3+) are associated with cognitive decline, risk of admissions with falls/ fractures and increased mortality.

The aim of the study was to quantify reduction in ACB score following structured medication review. The goal was to determine whether the frailty clinic was an appropriate setting for this.

Methods

Over a 5-month period the consultant geriatrician and GPwER calculated each patient’s ACB score. A medication reconciliation within their appointment facilitated deprescribing of high-risk medications. The HCA recorded ACB scores for all patients before and after medication review.

Results

54 patients attended the clinic. 18 patients had an initial ACB score of 0. The remaining 36 patients, had an ACB score of at least 1. Their mean reduction in ACB score was 1.2 points. Most pertinently, of the 19 patients with ACB scores of 3 or more, 12 left the clinic with a lower score and mean reduction was 2.1 points. One patient achieved a drop in score from 9 to 0.  Only 2 patients left with increased anticholinergic burden (in both cases, only increasin by 1 point).

Conclusions

Embedding the ACB score into the frailty clinics medication reviews were easily-achieved. This process is documented in clinic proformas, letters and the MDT discussion. This would be simple to transfer to similar settings.