MDT

Introduction 1 in 4 older individuals having emergency general surgery live with frailty, are more likely to have a longer hospital stay, readmission rate, morbidity and mortality. This underscores the importance of individualised approaches to care through Shared Decision Making (SDM). We introduced SDM into our surgical liaison service aiming to measure effectiveness and patient outcomes.

Methods Between October 2021 and September 2022, patients aged >70 years living with frailty admitted to the surgical unit were identified by an Older Persons Clinical Nurse Specialist (CNS). Involvement in treatment decisions was measured by using the patient and clinician SDM-Q9 questionnaire. Pre-admission as well as follow-up quality of life scores at 6 months using the EQ-5D-5L (0-100) as well as Decision Regret were obtained on subsets of patients.

Results Of a total of 76 patients seen by the CNS, follow-up data were available for 61 patients, clinician and patient SM-Q9 were completed in 54 patients. Clinicians were 10% more likely to strongly or completely agree that they explained choice available, 16% more likely to feel they explained treatment options compared with patients. Patients were less likely to feel completely involved in decision making. However, they were more likely to agree they understood clinical information presented them. Low levels of decision regret were ascertained at follow up where 18 patients agreed and 32 patients strongly agreed that a right decision was made of their care. Of 15 patients who underwent emergency laparotomy, mean EQ-5D scores across all domains from improved from baseline (69 vs 78).

Conclusions CNS led implementation of SDM is feasible, acceptable. Patients felt involved in their care and had lower levels of decisional regret. Encouraging and investing in an environment where health professionals take time to determine what is important to their patient can be associated with better outcomes.

Introduction:

Recent studies show the use of comprehensive geriatric assessment (CGA) in older patients with cancer can result in better quality of life, improved treatment tolerance and reduced hospital admissions, leading to international consensus that CGA should be routinely included in care. We have piloted an onco-geriatric MDT, consisting of oncologists, geriatricians and therapy input, alongside a rapid-access geriatrician-led onco-geriatric clinic

Method:

Referrals were invited from oncologists for older patients (>70) with a new diagnosis of cancer, with expected prognosis of more than 1 year, about whom they had concerns regarding their ability to undergo radical treatment due to co-morbidities, falls, cognitive impairment or social isolation. A CGA was completed prior to starting radical treatment in most cases. Performance status, Rockwood frailty score(RFS) and G8 score were calculated for all patients.

Results:

During the 24 week trial period, an MDT and clinic has run every week. A total of 32 patients have been discussed at MDT, with 22 seen in clinic, from cancer sites including colorectal, breast, urological and ovarian. Patient seen in clinic had an average RFS of 4.5 and G8 score of 13. All patients have seen a geriatrician, with most also seeing our physiotherapist. Interventions included medication review and rationalisation, anaemia review and treatment, referral to specialist memory and continence services, blood pressure optimisation and completion of a treatment escalation plan.

Conclusions:

Feedback from patients attending the clinic has been resoundingly positive, with 100% of patients rating their service experience as “good” or “very good” and praising the time to talk about their health as a whole. Follow up of clinic patients is in progress, identifying emergency admissions alongside treatment toxicities and complications within this group, as well as whether G8 is an appropriate screening tool for clinic review, to secure the long-term future of the service.

During the pandemic, diagnosing Dementia has declined significantly by over 35%. A Collateral history refers to information obtained from individuals other than the patient, such as family members, friends, or caregivers. This information is often crucial and can provide valuable insights into a patient's medical history, symptoms, behaviours, and social circumstances. Studies have proven a collateral history can enhance medical assessment, improve treatment planning, aids safety concerns and act as a diagnostic aid. By obtaining information from multiple sources, Doctors can compare the patient's account with the observations and experiences of others. This can help in corroborating or identifying discrepancies, leading to a more accurate diagnosis. 

A convenient sample of 20 patients investigating the benefit of a collateral history using it as enhanced information to aid diagnosis of dementia earlier, and in turn, commencing treatment earlier.  

Results showed the collateral history provided more information enabling diagnosis of a delirium or a diagnosis of dementia. If it appeared the diagnosis was dementia, the information was relayed in a multiple disciplinary approach and with multidisciplinary agreement, treatment commenced. 

Early diagnosis of dementia is crucial as it allows for timely intervention, better disease management, and improved quality of life for both patients and their families. Collateral history aids in this process by capturing subtle changes in cognition and behaviour that may not be evident during routine clinical assessments. It provides a broader perspective on the patient's functioning over time and helps differentiate between normal aging and pathological cognitive decline. 

It is important to consider the collateral history limitations as a tool and use it in conjunction with other diagnostic tools to ensure an accurate and comprehensive evaluation.  

Introduction

People recently diagnosed with Parkinson’s disease (PD) may withdraw from physical activity because of PD symptoms or loss of confidence. We are conducting a feasibility trial of a remote physiotherapy intervention. To gain a broader understanding of attitudes to physical activity and physiotherapy, we surveyed people with early PD in UK.

Methods

We developed a questionnaire (JISC Online Surveys) about physical activity and remote physiotherapy. This was distributed on paper to local Parkinson’s UK groups, and online via Parkinson’s UK newsletter and social media. 

Results

We received 274 valid responses. The most frequent age category was 60-69 years (69%), and just over half of respondents were male (53%). Respondents of diverse ethnicities amounted to 2% of the total sample. For physical activity, the majority of participants reported a high or average level of physical activity, with only 11% reporting a low level. The majority of participants reported that regular exercise was extremely or very important for keeping well with PD. When asked about barriers to being active, the most common response was apathy (29%), followed by difficulties due to PD symptoms and feeling exhausted. These barriers may be amenable to physiotherapy intervention, and we asked participants about their experience of physiotherapy. 47% reported that they had never had physiotherapy for PD; the remainder ranged from single assessment to more than one course of physiotherapy. In terms of telemedicine, 36% reported having a videoconsultation with a doctor or therapist in the last year, with the majority of these participants reporting a good experience; whereas 7% reported concerns with technology.

Discussion

The majority of respondents were enthusiastic about physical activity and believed this was helpful for their wellbeing. Barriers to exercise may be amenable to physiotherapy intervention. Digital monitoring and telemedicine were acceptable to many respondents.

Background

Person-centred structured medication review (SMR) is associated with reduced polypharmacy, adverse drug reactions (ADRs), admission to hospital and mortality. Our service development aimed to explore the cost-efficacy of a multi-disciplinary team (MDT) providing SMR as part of a comprehensive geriatric assessment for care home (CH) residents.

Method

We established an MDT consisting of a consultant geriatrician, specialist clinical pharmacist, two general practitioners, clinical fellow, physician associate and frailty paramedic practitioner. Training on SMR was given by the pharmacist to other team members, with further support offered through the pilot.

Results

A total of 785 residents were reviewed across 20 CH sites during the initial 6-month pilot. Overall, polypharmacy was reduced by an average of 1.33 medicines per resident (8.32 to 6.99). The drug classes most commonly deprescribed were laxatives, antidepressants, lipid lowering drugs, opioids, and nutritional supplements. Medicines altered included three classes known to cause 40% of avoidable hospital admissions due to ADRs(1): diuretics (stopped/changed for 42 residents), antiplatelets (stopped for 34 residents) and anticoagulants (stopped/changed for 26 residents). Annual projected medication savings totalled £131,462(net), with an average saving of £169 per resident (range £63- £367). Drug classes with the largest cost impact were nutritional supplements (40% total savings), laxatives (12%), opioids (12%) and anticoagulants (11%). Carbon footprint savings from the 12 inhalers stopped during this phase totalled 1,323,098 gCO2e per annum: equivalent to 4562 car miles.

Conclusion(s)

A multi-disciplinary approach to medication review was shown to reduce inappropriate polypharmacy in care home residents. This intervention was associated with significant projected cost savings. Future work should aim to target SMR to patients with the highest rates of inappropriate polypharmacy.

References: 1. Howard, R. L. et al. Which drugs cause preventable admissions to hospital? A systematic review. British Journal of Clinical Pharmacology vol. 63 Preprint at https://doi.org/10.1111/j.1365-2125.2006.02698.x (2007).

Introduction:

Perioperative medicine for the Older Patient undergoing Surgery (POPS) is an established, evidence based medically led service across many Trusts. However, with consultant workforce constraints, the aim was to determine if an alternative ACP led model of care, with consultant geriatrician oversight, delivered the same benefits.

Method:

• A senior nurse, with POPS expertise, was seconded for one year to oversee the project. NHS Elect network supported, from February to October 2022, with monthly meetings, data analysis and facilitated shared learning from other sites

• An ACP from the medical frailty service worked alongside to develop perioperative expertise and allow future sustainability.

• Geriatrician with interest in perioperative care was appointed in May 2022 and contributed to service development and delivery.

• Patients with frailty were identified proactively through the daily board round and surgical handover. Those identified were reviewed using a comprehensive geriatric assessment. Medical advice was sought as required.

• Prospective data collected on all patients seen

Results:

Patient data analysed (n=404) from January to August 2022. Length of Stay (LOS) reduced for patients over 65 years of age living and with frailty by 4 days (17 to 13 days). Variation in LOS reduced from 46 to 26 days. Readmission rate was 6% (26/404). Average Trust rate of 11%. Introduction of POPS improved the National Emergency Laparotomy Audit geriatric specialist input from 10% in Q1 2020/2021 to 91% of patients in Q4 2021/22.

Unmeasured benefits include upskilling of nursing staff on the wards identifying frailty and discharge planning. Shared decision making influencing non-surgical treatment for patients for better outcomes. Reduction in calls to medical registrar post POPS introduction.

Conclusion:

This pilot successfully demonstrated the role of ACP in service design, care coordination and timely medical review to deliver a reduction in length of stay and readmission rate.

Background

West Lothian has 17 care homes with 881 residents. General Practitioners (GP) undertake annual review of all residents, including medication review, with variability between practitioners.

Introduction

Multidisciplinary team (MDT) working is the cornerstone of comprehensive geriatric assessment. MDT meetings are an excellent environment for shared learning and discussion. We applied this principle to a 2-year project delivering structured MDT medication reviews of care home residents.

Methods

Funding was secured for a consultant geriatrician (0.5PA for 2 years, £6500 per year) to join the Lead GP, Integrated Care Pharmacist and care home nursing staff in setting up an MDT for each care home. Complex patients were discussed in monthly MDT meetings, focusing on medication reviews. Shared decisions were documented on primary care clinical notes and amendments made to prescriptions. Where necessary, further GP review assessed subsequent impact of medication changes. Annual cost savings were calculated based on the current Scottish Drug Tariff(1). Qualitative feedback was sought from all members of the MDT.

Results

43 residents from 9 Care Homes were discussed in 11 MDT meetings between Jan-Dec 2022. Average age was 83.3 years (64.9-101.3), 63.4% were females. In total 6 new medications were started, while 87 medications were stopped. The dose was increased in 5 medications but decreased in 37 medications. Total annual savings were estimated at £6657, an average of £155 per resident discussed. Feedback from all members of the MDT was positive, particularly for improving patient care and increasing knowledge and confidence in managing this frail population.

Conclusion

Structured MDT reviews ensured patients were on appropriate medications focusing on improving symptoms and quality of life, in keeping with principles of realistic medicine. The estimated annual savings exceeded the funding invested, making this intervention cost-effective. We plan to scale this up further in Year 2 of this project.

Reference

1.            Public Health Scotland, Scottish Drug Tariff,

Introduction ‘Older People in Hospital Standards’ (2015) identifies that Older People should have care/treatment in the most suitable settings. In University Hospital Monklands (UHM) a liaison service was provided to frail patients who needed care outwith our older peoples’ wards (eg Surgical wards), led by clinicians (Consultant Geriatrician/ specialty doctor) twice weekly with support from Frailty nurses (FN). Patients were referred via multiple routes (email, letter, phone). Our aim was to develop a single point of referral, to increase capacity, be more responsive and FN led. Methods: We developed the FN workface by recruiting advanced/ trainee advanced nurse practitioners. We developed an electronic referral and Electronic Frailty alerting in October 2022. We provided education/visual prompts about the service and embedded the referral pathway/criteria in the hospital ‘huddle’ and safety briefs. From December 2022, all patients referred were reviewed by a FN. Results: From December 2022, the number of electronic referrals has increased by 70% ( fig 1). The number of patients who have a recorded clinical frailty score (CFS) has increased from 50 % to 98% ( fig2) We now have a 5day service, where referrals are seen the same day by FN. We reduced the need for clinician input from 2 sessions/week to 0.5 sessions/week, allowing redistribution of workload. There has been no change in outcomes of discharge planning/rehabilitation/repatriation for patients before and after the change. Conclusion: The number of referrals made electronically has increased – allows a more responsive service, standardises the pathway and reduces FN time in responding to phone calls/emails. This has increased the number of patients who have a CFS completed. It has released clinician time to deliver care in other parts of the system. Ongoing plans include developing this to be fully FN led and using it in planned care eg in preoperative admissions.

Background

North Central London Integrated Care System has invested in a pre-hospital programme where geriatricians and emergency physicians support London Ambulance Service via a telephone ‘Silver Triage’ in their clinical decision making on whether to convey an older person living with frailty to hospital. The results of the scheme are described elsewhere.

Methods

452 cases were discussed with Silver Triage between November 2021 and January 2023. Paramedics using the service were sent a survey including a free text question on how the scheme could be improved which was analysed using thematic analysis.

Results

We received 103 comments on how we could improve which fell into three key themes each with subsequent subthemes:

1. Improving access to the service – this included expanding into a 24-hour service, accessible in other areas of London, available to emergency medicine technicians and for people not living in care or nursing homes.

2. Improving information about the service – this included education for paramedics on who to refer but also increasing awareness of the scheme in local emergency departments.

3. Improving delivery of the service – this included requests for video conferencing, reported technology issues and frustrations with pathway breakdown following triage. For example if the agreed plan was not to convey and to support through rapid response or district nurse services, lack of availability led to conveyance to hospital contrary to outcome of triage.

Conclusion

Whilst the Silver Triage scheme has been well received by paramedics there are clear areas for improvement to ensure sustainable and equitable pre-hospital care for older people living with frailty.

Introduction The Fracture Liaison Service (FLS) is a multidisciplinary service for individuals over 50 presenting with fragility fractures. It is designed to assess future fracture risk, and appropriately diagnose and manage patients with osteoporosis.1 At Wrightington, Wigan and Leigh Teaching Hospitals (WWL), concerns were raised that access to this service was poor, meaning some patients presenting with fragility fractures were not receiving appropriate management to reduce risk of recurrent fracture. This project was designed to increase referrals to the service. Methods A cohort was identified of patients over 50 presenting to WWL with a fractured proximal humerus or distal radius/ulna over a three-month period from January to March 2021. These presentations were reviewed to identify the proportion of these patients who had been appropriately referred to the FLS. Following the initial audit, the FLS referral pathway was reviewed, and discussions were held with multidisciplinary teams (MDTs) in radiology and orthopaedic surgery to highlight the importance of appropriate bone health risk assessment. The number of patients referred each week by radiology were assessed before and after these discussions to assess whether access to the FLS had improved. Results In the initial audit 4.2% of patients with humeral fractures (n=24) and 0% of patients with radial/ulnar fractures (n=29) were appropriately referred to the FLS. Mean weekly referrals from radiology to the FLS significantly increased following the MDT discussions (mean 6.14, SD 4.40 vs mean 22, SD 6.38; t=6.71 p001 conclusions pre-existing referral pathways to the fls were found be resulting in many patients not receiving appropriate care for their bone health. a simple review of pathways, and discussion with mdts other departments was way improving access therefore hopefully reducing risk fracture recurrence. references 1. https: />/theros.org.uk/media/1eubz33w/ros-clinical-standards-for-fracture-liaison-services-august-2019.pdf [Accessed 18.05.2022]