MDT

Background

Older people account for >40% of acute hospital admissions. Delivering alternatives to hospital admission and community-integrated care closer to home are increasing priorities. We aimed to develop an Emergency Department (ED) Frailty MDT to provide rapid assessment, early Comprehensive Geriatric Assessment (CGA), and reduce inpatient admission rates for frail older people.

Methods

From November 2023 to April 2024, a newly formed Royal Infirmary of Edinburgh ED Frailty team delivered CGA for older adults aged ≥75 (≥65 if care home resident) with Clinical Frailty Scores ≥5 in the ED. The ED Frailty Team consists of an Emergency Medicine Consultant with an interest in Frailty, a Consultant Geriatrician, two Frailty Advanced Nurse Practitioners, an Occupational Therapy Advanced Practitioner, Occupational Therapists and a HomeFirst Social worker. We prioritised patients who were most likely to achieve same-day discharge. We built on strong integrated community pathways including Hospital @ Home, Rapid Access Day Hospital, and Discharge2Assess. We evaluated efficacy and safety using readmission and mortality rates.

Results

We reviewed 344 patients and discharged 209/344 (60.7%) of frail older patients who were awaiting medical beds. We discharged 114/209 (54.5%) with Hospital @ Home; 49/209 (23.4%) with rapid access Day Hospital; 21/209 (10%) home with GP follow-up; 18/209 (8.6%) home with no follow-up; 5/209 (2.3%) home with other community follow-up; and 2/209 (1%) home with ambulatory care. Discharged patients had a 19.4% 30-day representation rate and a 5.8% 30-day mortality rate. Admissions from ED amongst Edinburgh city residents reduced from 60% to 43% in 75-85 year olds and from 52% to 46% in the 85+ age group.

Conclusion

ED Frailty MDTs can effectively deliver CGA in an Emergency Department setting, facilitating admission avoidance and delivery of integrated care closer to home that is effective and safe.

Introduction

Geriatric medicine is inherently complex and requires multi-disciplinary integration. Simulation-based training has been recognised by the Joint Royal Colleges of Physicians’ Training Board and the Royal College of Nursing as a method to enhance learning and improve patient outcomes. This project aimed to develop a multi-professional simulation programme within care of the elderly to mimic the multi-professional clinical practice that takes place on geriatric hospital wards.

Methods

A total of ten half-day simulation sessions have been run across two sites in two years. The scenarios cover frailty, orthogeriatric post-operative complications, acute delirium, Parkinson’s disease, thrombolysis and end of life care. The sessions were attended by 57 participants, including 24 doctors, 20 nurses, 7 nursing students, 4 healthcare assistants and 2 physician associates. Quantitative and qualitative questionnaires conducted pre- and post- simulation were used to assess confidence levels and attitudes towards simulation as a learning tool.

Results

Both pre- and post- simulation, candidates had the most confidence in managing end of life situations, and least confidence in managing acutely unwell patients with Parkinson’s disease. Confidence levels for managing common geriatric scenarios increased by an average of 21% after candidates participated in the simulation session. Thematic analysis highlighted the importance of collaboration within a team to enhance a sense of belonging, and pro-activeness of staff to highlight deteriorating patients to colleagues and family members.

Conclusions

Simulation that mimics the ward environment is an effective tool in increasing the confidence of the multi-disciplinary team looking after geriatric patients through exposing candidates to complex situations and increasing awareness of the roles within the team. The simulation sessions have highlighted clinical areas that require further education within the Trust, such as thrombolysis. Future development of the simulation will aim to adapt the scenarios for use of the wider multidisciplinary team, incorporating therapists and pharmacists.

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.

Introduction
An Acute Frailty Team pilot was launched in December 2022 at the QEH. The aim was to reduce unnecessary hospital admissions and length of stay (LOS) by providing interventions in the Emergency Admissions Unit (EAU), through comprehensive geriatric assessment. Following the pilot’s success additional recruitment was made to the multi-disciplinary team (MDT) and the service revaluated. The MDT consists of a Consultant Geriatrician, Specialist Frailty Practitioner, Frailty Fellow, Physiotherapist, Technical Instructor, Occupational Therapist, and Pharmacist.

Method
To allow comparisons a pre-pilot control group audit of 100 patients ≥65 with a clinical frailty score >5 was undertaken. This data has subsequently then been compared to a phase-1 (Consultant Geriatrician, Specialist Frailty Practitioner team) audit of 121 patients and a phase-2 (full MDT) audit of 133 patients with the same parameters.

Results

The creation and expansion of the acute frailty team has reduced the average length of stay from 13.8 days, pre-pilot, to 9.4 days in phase-1 and subsequently been maintained at 9.56 days during phase-2. More frail patients are now being discharged from the emergency admission unit (EAU). Pre-pilot 7% of patients were discharged from EAU, increasing to 13% during phase-1 and 18.75% phase-2. 16% of patients were originally discharged within 72 hours of admission, this increased to 20% during phase-1 and 24.81% phase-2. This is also reflected in 7-day discharge data (37%, to 39% to 44.36%).

Conclusion(s)
MDT expansion of the acute frailty team at the QEH has resulted in improved recognition and holistic assessment of frail patients’ needs and reduced their length of stay.

Introduction

Shared Decision-Making (SDM) is increasingly expected in most aspects of UK medical practice and can be particularly important for older patients to guide goals of care. Treatment Escalation Plans (TEP) summarise medical intervention to be attempted in the event of acute deterioration. Current guidance advocates SDM in TEP but it is unclear whether this is considered practicable by clinicians. This study aims to understand clinicians’ perspectives on SDM in TEP for older patients in the acute medical setting.  

Methods

This was a qualitative study following a relativist constructivist approach. 26 consultant and registrar doctors were recruited from general internal medicine, intensive care, palliative care and emergency medicine. A clinical doctoral student conducted semi-structured interviews including vignettes of older multi-morbid patients with capacity to discuss treatment escalation. Reflexive thematic analysis was performed. Ethics approvals were obtained from the Health Research Authority 22/HRA/4387.

Results

Three themes were generated: ‘An unequal partnership’, ‘Options without equipoise’ and ‘Decisions with shared understanding’. SDM incorporating patient preferences with clinical opinion was seldom perceived to be appropriate. Clinical complexity and use of intuition, together with lack of perceived moral equipoise, motivated clinicians to develop medically acceptable TEPs. Shared understanding with the patient and family and avoiding conflict were important.

Conclusions

Contrary to current guidance, SDM was considered a potential barrier to formulating appropriate TEPs in the acute medical setting. This study suggests potential incompatibility between policies prioritising patient autonomy and the right to make unwise decisions, and those stating clinicians’ prerogative to determine realistic chance of treatment success and not provide intervention considered medically inappropriate.  

Introduction: Many countries are facing an ageing population, and this is also evident in Singapore. To alleviate this matter and to cope with the increasing number of older persons today, nursing homes are also expanding. Residents of nursing homes are often frail and are at higher risk of multiple hospital admissions. On many occasions, the benefit of conveying the frail residents to acute hospitals is unclear and may even cause more harm. We implemented an acute hospital-nursing home collaborative pilot in two nursing homes with an objective to reduce emergency department visit and inpatient hospitalization among nursing home residents. We aim to study the experiences of healthcare personnel who were involved in an acute hospital-nursing homes collaboration in managing acutely ill residents.

Methods: Explorative qualitative interviews were conducted with fifteen nursing staff from two nursing homes involved in the pilot collaboration. The interview transcripts were thematically analyzed.

Results: The study delved into five key thematic areas: knowledge and understanding, service satisfaction, challenges, enablers, and service improvements. It revealed that a significant portion of staff lacked a comprehensive understanding of the collaboration's objectives. Nevertheless, there was a consensus that they found reassurance in the accessibility of hospital providers without immediate activation of emergency services. Nursing home staff acknowledged enhancing their ability to identify residents requiring escalated care through this collaboration. The interventions utilized, such as the NEWS assessment tool, hospital transfer forms, and teleconsultation portal, were noted for their user-friendliness. Challenges encountered included pressure from next-of-kin favouring treatments in acute hospitals over nursing homes and insufficient on-site resources. Identified enablers included a robust support system and the competency and motivation of nursing home staff to enhance residents' care, facilitating collaboration. Recommendations for improvement highlighted the need for training and skill development among nursing staff and workforce enhancement to bolster collaboration adherence.

Conclusion: These key themes highlight the significance of the collaboration between nursing homes and hospitals in improving care for residents, while also acknowledging the challenges and areas for future improvements.

Introduction:

BGS reports in its 'Case for more Geriatricians' that the number of people age over 85 is set to double by 2045. As well as Geriatric specific policies in the Ageing Well programme of the NHS Longterm Workforce Plan there are plans to expand the number of allied health professionals including Physician Associates (PA). We set out to improve PA students knowledge of and confidence in managing geriatric patients with a bespoke teaching programme culminating in a novel bleep simulation.

Methods:

We identified the students needs with a preliminary survey and then created a teaching programme on medical topics and issues common to geriatric wards with weekly lectures and small group work. The programme culminated in a bleep simulation where students were contacted via bleep to come to different parts of the medical education centre and respond to scenarios which would be common on geriatric wards. These included reviewing unwell patients and issues such as aspiration, constipation and urinary retention. The students were required to amend or create prescriptions and interpret test results with access to the BNF and relevant local guidelines.

Results:

Students were asked how useful the simulation was and how much it had improved their confidence in working on geriatric wards. The average score for both statements was greater than 9/10. The students were asked before and after the simulation how confident they were responding to bleeps and managing clinical scenarios in geriatric patients. Both scores doubled following the simulation to 6.7/10 (from 2.5 and 3.3 respectively).

Conclusion:

The Faculty of Physician Associates curriculum does not necessitate placements in geriatrics and its matrix of core clinical conditions does not include any specific to geriatrics. Through a bespoke teaching programme and a novel bleep simulation we increased PA students confidence in managing geriatric patients.

Background

NICE (2023) Shared Decisions Making (SDM) Guidelines ensure Health Care professionals work together with a person to reach a decision about care based on their individual preferences, beliefs, and values.

Local Problem

We conducted an Audit across our community services to assess NICE SDM, achieving 71% compliance. Results informed the project problem statement “Clinical Teams are not fully compliant to NICE SDM guidelines therefore a shared decision-making approach is not guaranteed”.

Methods A fishbone diagram was applied to understand why SDM wasn’t routinely occurring in clinical practice. Our aim is to achieve organisation wide adherence to SDM. We propose a multi modal approach to increasing awareness of SDM across the organisation. We used a driver diagram working backwards from the goal, identifying the drivers and determining the project activities. Interventions Due to the enormity of rolling out a pan-organisational programme we decided to use the Frailty NHS@Home virtual ward to test and learn before greater adoption. We firstly processed mapped how the “What Matters to you?” question is embedded into our Comprehensive Geriatric Assessments. A decision support grid for treatment option decision making was created for dehydration or high risk of dehydration within the NHS@Home service, adapted from Marrin et al (2014). Three options are described underpinned by five questions. Feedback from Patient and public involvement ensured the language was appropriate. After the first PDSA cycle, the tool was reviewed by the project team and two further questions were added, “Did you understand the options which were explained to you?” and “What matters most to you as we decide together how best to treat your dehydration?”.

Conclusion

A re audit and colleague survey will reveal increased knowledge and understanding of the SDM concept. We continually seek Feedback from individuals who use our services for their experience of SDM processes.

Introductions A suspected urinary tract infection (UTI) is the most common reason to prescribe antibiotics in a frail older patient. Therefore, correct recognition and documentation of UTIs, as well prescribing of antibiotics, is important for optimising patient care.

Methods We reviewed UTI antibiotic prescribing practice across the Health and Ageing Unit (HAU) wards at Kings College Hospital over a two-month period. Weekly data we collected from all patients commenced on antibiotics for a suspected UTI highlighted key areas for improvement. We designed and delivered a multifaceted educational intervention to all healthcare professionals caring for older adults across the HAU. This consisted of teaching sessions, distribution of posters, and board round reminders.

Results A further two months of data post-intervention showed improvements in several outcomes. Correct prescribing rose from 61% to 93%. The number of prescriptions with stop dates went up from 50% to 68%. The number of patients with urine samples processed in the laboratory rose from 64% to 93%. We also saw an improvement in the management of patients with catheter associated UTIs.

Conclusions A multidisciplinary team intervention of teaching and visual cues improved the management of UTIs. This shows the power of multifaceted educational interventions for improving the care of older adults.