Prescribing and medication management

Introduction At Wrightington, Wigan and Leigh we admitted over 400 patients with hip fracture diagnosis in 2023. As part of ortho-geriatric review, denosumab treatment would be utilised in a cohort of patients where this is appropriate, in line with NOGG guidelines. Traditional model of delivering first dose after outpatient appointment led to delays in treatment initiation and did not address the significant risk of “imminent fracture” which was recognised in the latest NOGG guidelines. The aim of this project was to reduce delays in denosumab treatment initiation by introducing consenting process during hospital stay led by ortho-geriatric Advanced Clinical Practitioner.

Method Utilising hospital electronic records, a sample of patients was selected from patients admitted in 2022 (19 patients), 2023 (19 patients) and 2024 (6 patients). Time of decision to treat with denosumab to time of first dose administered was used as the outcome measure. Alongside this, analysis of time to outpatient appointment was completed which was where the pre-intervention consent was taken. Intervention of inpatient consent being taken was implemented in September 2023.

Results The average length of time from clinical decision being made to first dose of denosumab being administered was 187 days in 2022 sample, 76 days in 2023 sample and 27 days in 2024 sample. The governance around consent process was established and adopted by the whole ortho-geriatric team. Waiting times for outpatient bone health clinic were on average 240 days in 2022, 164 days in 2023 and unknown in 2024 cohort.

Conclusion(s). Introduction of ward-based consent process for patients who are suitable for denosumab led to significant decrease in delays in time to first dose. This ensures that patients benefit from bone protection in a timely manner, as their risk of refracture is greatest in the first 6 months post index fracture.

This service evaluation reviewed the impact of the Perioperative Care of Older People Clinic (POPS) on Anticholinergic Burden (ACB) in older surgical patients and identified areas for improvement. The study assessed 75 patients aged ≥65 years, revealing widespread anticholinergic use. Among patients on anticholinergics, 34% experienced a reduction in ACB post-POPS review. However, maintaining these changes at ≥6 months was challenging, with 50% of patients experiencing a change in their ACB score due to new prescriptions or the re-initiation of old medications. The study identified communication gaps at the POPS-primary care interface affecting de-prescribing efforts, underscoring the need for improved discharge letters, systems to flag high ACB patients and a universal ACB tool.

Introduction

The UK's ageing population is increasingly undergoing surgery, and older adults are at higher surgical risk partly due to anticholinergic use. POPS is a relatively new initiative aimed at reducing ACB in this demographic, but the sustainability of these reductions is not well understood. This service evaluation aims to fill this gap and suggest solutions for maintaining reduced ACB levels.

Methods

Retrospective data from 75 patients from 2022-2023 who met the criteria for ACB evaluation pre- and post-POPS review, with follow-up at ≥6 months, were included. Results Post-POPS, ACB was reduced in 34% of patients, with a median decrease of -2. However, ACB increased again in 50% of patients at ≥6 months, with re-initiation of amitriptyline and furosemide contributing to the rise in 67% of these cases.

Conclusions

CGA effectively reduces ACB in older surgical patients, but sustaining these reductions poses significant challenges. Communication difficulties at the POPS-primary care interface likely contribute to the re-initiation of medications, indicating a need for standardised discharge summaries and a universal system for evaluating and flagging high ACB patients to maintain improvements.

Introduction 

Converting oral Parksinon’s disease (PD) medications to transdermal Rotigotine is sometimes required when patients have swallowing difficulties. Correct dosing is important to avoid under-treatment and deterioration of PD symptoms. Conversely, excessive dopamine agonist can cause hallucinations and confusion. In the UK, 2 main dose conversion calculators exist: PD Med Calc1 and OPTIMAL2, both utilising different formulae. We compared both to identify any dose discrepancies in their recommendations, and select one for use within revised trust guidelines. 

Methods 

We conducted a retrospective analysis of 22 cases from pharmacy data of 1400 prescriptions issued between January 2021 - July 2022 for patients switched from oral PD medications to a Rotigotine Patch whilst admitted to a UK teaching hospital. We calculated the recommended Rotigotine patch dose from each patient’s usual oral medication regimen using both the PD Med Calc1 and OPTIMAL2 calculators to identify discrepancies. 

Results 

In 86% of cases (19/22) there was a difference between doses suggested by both calculators. Of these, 95% (18/19) showed OPTIMAL recommended doses 20-200% higher than PD Med Calc. In 5% (1/19) OPTIMAL recommended a marginally lower dose than PD Med Calc.  

Conclusions 

In dopamine agonist naive patients, PD Med Calc recommended a lower starting Rotigotine dose than OPTIMAL. Most admitted PD patients on patch conversion were older adults, and this population is particularly vulnerable to the side effects of excessive dopamine agonist exposure. The authors recommended using PD Med Calc within revised trust guidelines to minimise negative sequelae and ensure dosing consistency.  1 PD 'Nil by Mouth' Medication Dose Calculator http://pdmedcalc.co.uk/ 2 OPTIMAL Calculator - A Guideline for the OPTIMAL management of inpatients with Parkinson's Disease. http://www.parkinsonscalculator.com/index.html  

1. Introduction

Care home residents have a greater incidence of frailty and co-morbidities. Polypharmacy and inequitable access to integrated healthcare are confounders to positive outcomes in this cohort. Providing proactive care through the Enhanced Health in Care Homes (EHCH) Framework seeks to address these inequalities using multidisciplinary team (MDT) working.

2. Method

A pilot MDT intervention was delivered across eleven older peoples care settings with the most ambulance conveyances in a London borough known for its aging population. MDT members were from general practice (including pharmacist), geriatrics, ambulance service, district nursing, palliative care, psychiatry, social care, integrated care board and senior care home staff. The intervention was refined iteratively over five months via a Plan-Do-Study-Act cycle. The MDT undertook comprehensive geriatric assessments, advance care planning and structured medication reviews. Outcomes were documented in personalised care and support plans (PCSP).

3. Results

Sixty-nine of the most complex patients were selected to receive the intervention. 100% of these patients had a PCSP created post-intervention. A resultant system culture change led to a three-fold increase in the number PCSPs across all care settings. There was a reduction in 999 calls for 57% of MDT patients (across 8 settings) and there was 24% fewer 999 calls and hospital conveyances across the wider patient group in all MDT care settings. MDT professionals and care home staff reported high satisfaction and valued shared learning and clinical decision-making.

4. Conclusion(s)

This intervention addressed health inequalities of care home residents with a clear thread of advocacy for patients. Proactive personalised care planning offered opportunities for earlier diagnoses, treatment, and swifter recognition of the dying phase of life. Primary care interventions within EHCH framework could be augmented by this MDT approach for a more complex cohort of care home residents with severe frailty and greater co-morbidity profile including dementia.

Introduction
In older adults, anticholinergic burden (ACB) is associated with serious adverse effects
including delirium, falls, functional decline, cognitive decline and death. We carried out a quality improvement project in a geriatric ward, aiming to reduce the percentage of older adults with high ACB scores on discharge by 15% from a baseline of 48% over a period of 3 months.
 

Method
A pre-interventional analysis of all patients discharged from a single acute geriatric ward in
Changi General Hospital was performed. A pre-intervention survey was conducted to assess awareness among physicians of ACB and tools used. Fish-bone diagram, pareto chart and driver diagram were used to identify root causes, highlight the barriers and to prioritise
interventions. Interventions in the form of educational posters on ACB, non-
pharmacological management of delirium and behavioural symptoms of dementia were made available at the ward. ACB scores were generated for all patients on discharge, using
an online ACB calculator 1 , which combined the use of 2 validated scales: anticholinergic
cognitive burden scale 2 and the German anticholinergic burden scale 3 .

Results
396 patients were included in the analysis. Median percentage of patients with high ACB scores (≥3) on discharge was reduced from 48.4% pre-intervention to 16.1% post- intervention. Out of 14 physicians surveyed pre-intervention, 21.4% was unaware of theterm “ACB” and availability of ACB scoring systems.

Conclusion
An education approach is effective in raising awareness and reducing use of anticholinergic medications in an acute geriatric ward. This highlights the importance of incorporating ACB awareness and the tools into geriatric department teaching programmes.
References
1. ACB Calculator. (n.d.). https://www.acbcalc.com/
2. Boustani M, et al. Ageing Health. 2008. 4(3). 311-320.
3. Kiesel EK, et al. BMC Geriatr. 2018. 18. 239.

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.

INTRODUCTION

Polypharmacy represents a significant challenge in the vulnerable elderly population, where concurrent use of multiple medications increases the risk of interactions and adverse reactions, often precipitating acute events and complicated hospital stays. This necessitates thorough medication reviews to mitigate these risks; a hospital admission allows for such opportunities.

METHODS

This project aimed to evaluate and address the medication burden among elderly patients, following WHO's Global Patient Safety Challenge: Medication Without Harm. 50 patient’s medications were reviewed on a elderly care ward over the space of 3 months. A ward pharmacist and a senior member of the medical team critically evaluated inpatient charts on a twice weekly basis. Any changes made to the medication regimens were documented; additionally, the general practitioner was informed of any changes.

RESULTS

Initial data indicated that 66% of patients were on five or more medications, with a high incidence of falls and a notable anticholinergic burden. On review of the 50 patients a total number of 36 drugs were de-prescribed, 38.9% were inappropriate anti-hypertensives, 13.8% vitamins amongst others.

CONCLUSIONS

This project has been an enlightening endeavour, teaching us the critical nature of addressing polypharmacy. We have learned that interdisciplinary collaboration, regular medication reviews, and patient education are key to managing this complexity. To ensure long-term sustainability, we plan to institutionalize pharmacy board rounds and implement mandatory medication reviews. We aim to work closely with primary care to maintain continuity post-discharge. These efforts are expected to foster a culture of mindful prescribing and medication safety.

Background: NICE Quality Standard (QS) 164 – QS1 states; Adults with Parkinson's have a point of contact with specialist services. This will facilitate continuity of care and access to information, advice, care and support when they need it. QS4 states; Adults with Parkinson's disease in hospital or a care home should take levodopa within 30 minutes of their individually prescribed administration time.

Introduction: To increase opportunities in meeting NICE QS’s consistently, Parkinson’s Specialist Nurses introduced Parkinson’s Champions. Individual studies consistently find that champions are important positive influences on implementation effectiveness. Over half of people with Parkinson’s don’t get their medications on time in hospital. This can cause stress, anxiety, immobility, severe tremors, and in some extreme cases death.

Method

Supportive structures that enabled the development and maintenance of our Champions Network:-

Clear Role Profile and Measurable Objectives

Provision of Resources/Tools

Ongoing Education/Training

Peer Support/Networking

Recognition/Appreciation 

PDNS leadership/support

Energy & Perseverance

Results: The Get it On Time Audit (GIOT) looked at Parkinson’s medications given more than 30 minutes early, on time and more than 30 minutes late. Following multiple interventions including promoting leadership and education within each dept, input to medicines policy, incident reporting and development of a learning module, On time medication administration improved from 58% to 80.05% compliance.

Champions were not experts in Parkinson’s when we started, through the process of undertaking the role, they have gained expertise and serve as an ongoing resource to their peers.

Conclusion: Our aim of having champions who enhance staff’s knowledge and skills so care delivered to persons with Parkinson’s is consistently safe and effective is being realised.

Investment in them, as demonstrated by audit results, is rewarded with more consistent meeting of NICE QS 164 and thus improved patient outcomes.

Our Champions network model will be shared with the Parkinson’s Excellence Network.

Background:

Heart Failure (HF) is a major cause of poor health, hospitalisation, and death, particularly amongst older people. Routinely prescribed HF medication can improve these outcomes, but many patients do not take their medications. Aims: To develop a tailored multi-component intervention to enhance medication adherence in older HF patients in preparation for a future pilot RCT. Objectives: To determine what intervention components and strategies are necessary and acceptable to create a support package to help and encourage HF patients to take their medication regularly. To develop an intervention manual to support the delivery of the proposed intervention.

Research methodology:

The study is an intervention development study using qualitative methods and an intervention development tool. To ensure that the experiences, beliefs, and preferences of HF patients are included the intervention is being co-developed with stakeholders including patients, informal carers, cardiologists, geriatricians, health psychologists, HF nurses and pharmacists using an iterative process where decisions about content, format, style and delivery are made together. Findings from previous work are being mapped to the Behaviour Change Wheel (BCW) and the Theoretical Domains Framework(TDF). Key factors known to improve adherence will be combined with motivational strategies and factors personal to each individual to develop a novel intervention. An expert panel including two HF patients will meet to co-design discuss, review, and agree the mapping decisions. Once the behaviours to be targeted for change are identified the TDF will be used to specify these behaviours in terms of who needs to do what differently, when, where how and with whom? During the process HF patients will also be recruited to participate in several focus groups to evaluate the outcomes of the mapping exercise and identify any concerns or potential barriers to delivery as the intervention is refined. Finally the intervention will be manualised ready for piloting.

Introduction

Zoledronic acid, a bisphosphonate used primarily for treating osteoporosis and other bone-related conditions, traditionally requires hospital visits for administration, which can be burdensome, especially for frail older patients. The administration of intravenous (IV) Zoledronic acid at home via Community Rapid Response Teams (CRT) represents an innovative approach to enhance patient care and accessibility while offering significant benefits to patients and healthcare services. Service Delivery CRT team is typically composed of highly trained nurses and doctors, equipped to handle potential adverse reactions promptly and effectively, ensuring patient safety. The involvement of CRT in administering IV Zoledronic acid ensures high-quality immediate care, maintaining the standards of good medical practice. In Caerphilly, our team has been successfully administering IV Zoledronic acid at home, having treated several patients without any complications, using a thorough, easy-to-use checklist process developed by our pharmacists. This checklist helps deliver prompt care in a safe and user-friendly manner.

Benefits

1. This approach enhances patient convenience and comfort, allowing them to receive necessary treatments without travelling, thereby reducing the physical and emotional distress associated with hospital visits.

2. It minimises exposure to hospital-associated infections, an essential consideration for immunocompromised individuals.

3. It can lead to improved adherence to treatment regimens, as patients are more likely to continue with therapy delivered in the comfort of their homes.

4. The reduction in hospital visits also alleviates the burden on secondary care facilities, allowing resources to be allocated more efficiently.

Conclusion

Administering IV Zoledronic acid at home via CRT not only enhances patient convenience and safety but also supports better healthcare resource management, potentially leading to improved treatment adherence and overall patient outcomes. We aim to develop this service further and extend it to other hospital requiring services like parenteral iron for heart failure.