Patient/ Family Involvement

Rationale: The Frailty Intervention Team (FIT) is a multidisciplinary team that provides a service to community based frail adults. This particular service is novel in the sense that it is a hospital based out-patient service as opposed to a frailty at the front door or a community based service, and has access to rapid diagnostic and intervention services. As this is a novel service a qualitative study was undertaken to assess patient satisfaction and guide the direction and development of future quality improvements initiatives.

Objective: To evaluate the satisfaction of service users with the implementation of an out - patient Frailty Intervention Team in a Model 2 Hospital setting.

Implementation: A mixed methods study was carried out in the form of a patient satisfaction survey which included quantitative questions as well as Likert Scale closed ended questions and open ended questions. This qualitative data was analysed by collating common words, creating word clouds to organize the ideas and suggestions made.

Outcome: Of the 150 surveys disseminated there was a 46.7% response rate. 66% of responders rated the services ability to meet their expectations as “excellent”. The main qualitative outcome of the survey was that service users felt they needed ‘a report sent to myself so I can remember’. Thus the Patient Action Plan Leaflet was developed where each discipline writes a summary of the intervention and advice provided during their assessment. A copy of this is then provided to the patient after each appointment.

Conclusion: This mixed method study resulted in service user feedback guiding a positive change to the provision of the service for the direct benefit of service users. Future research will aim to evaluate the effect of the Patient Action Plan Leaflet.

Introduction

Using a patient centred, valued based health care approach to reshape the acute frailty unit with the University Hospital of Wales. Our multi-disciplinary team provide our patients with a compressive geriatric assessment. The goal is to ensure our patients are treated in a timely, thorough manner to avoid deconditioning and hospital induced harm. We want our unit to be guided by the needs of our patient population.

Methods

A redesign of the service structure within the acute frailty unit was undertaken as a result a patient survey taken in 2021. The aim was to focus on concerns that patients had highlighted within their feedback; noting particular challenges with length of time spent within the accident and emergency department, access to analgesia and continence needs. We were able to note these concerns and work on redesigning our care model to focus on meeting these needs.

Results

Following these changes, we undertook focused interviews with patients. They speak positivity about their stay within our acute frailty unit; noting they feel listened to about their goals, they are kept up to date with their treatment plans and that the staff genuinely care. They continue to be concerned with regards to access to emergency ambulances and length of stay within the accident and emergency department.

Conclusion

Further significant changes have been made to the service structure following additional patient feedback. Our number of beds within the acute footprint of the hospital have been increased from 12 to 19. We hope that this, alongside a streamlining of the complete admissions process within the University Hospital of Wales, will allow us to continue to provide patient centred, valued based health care to our patient population.

Introduction Older adults are at risk of falls, which increases further in care homes. Due to the complexity of care home residents’ conditions and an increasing ageing population, it is important for care staff to have knowledge and understanding in falls awareness, prevention, and management in order to support their residents. Literature searches identified that barriers to care staff implementing falls prevention strategies included limited knowledge of staff and insufficient resources (including lack of staff training). There is scarce research regarding methods to deliver training to care staff, however emerging research in Virtual Reality (VR) as a training method had promise due to increased knowledge retention, and application into practice. Stakeholder patient and public involvement and engagement determined that VR as a training method had potential value.

Methods The second study as part of a multi-phase project, including two research phases and one technology development phase. The second research study was a mixed methods pragmatic study exploring the feasibility of the VR proof-of-concept, across seven care homes across the North West (n=40).

Results Engagement, immersion and enjoyment were key factors for acceptability of a training method. The training suited the learning styles of care staff, and VR was accepted as a training method. Utilisation of a case study resident increased empathy for the resident experience. Feedback for development included additional locations, scenarios, and interactable items. Barriers and facilitators of acceptability and adoption were identified.

Conclusion Identifying a potentially effective method of training for a complex intervention may influence the creation of future training programmes for care homes: to assist in increasing care staff knowledge, retention of information, and application of knowledge into practice. This in turn may improve the quality of care delivered and resident outcomes. Additional research is required to develop the proof-of-concept further, and feasibility tested further.

Introduction

During the COVID-19 pandemic, restricted hospital visitation policies were implemented to reduce the spread of the viral infection. As a result, telephone has become the main communication method despite the complexity of the elderly patients' medical and psychosocial issues. This has heightened anxiety and reduced satisfaction among patients and their families. This quality improvement project aimed at improving communication with patients' families. We introduced several strategies with the aim to update patients' families within 48 hours of admission and then at least once a week during patient's journey from admission to discharge.

Method

Retrospectively, all patients who were admitted to the ACM ward during the study period were included. Multiple Plan-Do-Study-Act (PDSA) cycles were implemented. As the first intervention, we added a new section on "Update patients' families" in our weekly harm free care document to identify patients' families who were not updated. Also, reminder emails were sent to all medical doctors to ensure that we record all discussions with families using "Discussions with patients and families' document". As the second intervention, a poster on "Harm Free Thursday and Update Friday" was displayed in the doctor's office. Face-to-face education was provided to new trainees to emphasise the importance of good communication with patients' families. Data was collected from electronic patient record (EPR) and Microsoft Excel was used for data collection and analysis.

Results

189 patients were included in the baseline audit which showed that only 49% of patients' families were updated weekly throughout the admission. Compliance in communication with families after the first and second cycle was 62% and 69% respectively. Following the second PDSA cycle, the percentage of patients' families who were updated within 48 hours of admission increased from 50% to 56%.

Conclusion

The project showed significant improvement in communication with patients' families with each cycle.

Introduction

Despite the high prevalence of frailty among older people, the clinical definitions and implications of frailty are not well understood by the public. Existing communication material is predominantly technical in nature and aimed at healthcare professionals.  This project integrated expertise in geriatric medicine, data science, user design and patient and public involvement (PPI) to develop an accessible visual communication resource on frailty that linked data stories, clinical perspectives and public views of frailty in later life.

Methods

We recruited three public contributors from the University of Edinburgh Advanced Care Research Centre’s PPI network to contribute to formulating the aims and objectives of the communication resource. We developed user personas and case scenarios to consider the intended audience for the communication resource and how they might interact with it. To ensure that all key messages were data-driven, we analysed quantitative survey data from the English Longitudinal Study of Ageing (ELSA) (n=7289), which included information on sex, age and health deficits used to calculate standardised Frailty Index scores. We developed a storyboard to present each piece of information.

Results

Using an iterative co-design process with our PPI contributors, we tested different ways of communicating frailty information and ELSA data insights. Visual elements were incorporated to enhance engagement and informativeness. Core themes of the final 6-page resource included placing frailty in the context of resilience, healthy ageing and interactions with common health issues such as living with multiple long-term conditions. The prevalence of frailty and differences between mild, moderate and severe levels were communicated using person-examples inspired by ELSA data.

Conclusions

We produced a communication resource, informed by a co-design process, that addresses a key gap in existing frailty resources. Our work shows the value of integrating user experience research methods, public patient involvement and data insights to enhance health communications.

Introduction: One in three hospitalised patients die within 12 months of admission, rising to 45.6% in individuals aged 85 and older. Resuscitation is rarely successful in this patient group. Most older persons are happy to engage in discussions regarding resuscitation and patients' and relatives' involvement is recommended by the General Medical Council and Royal College of Physicians.

We aimed to increase the number of resuscitation and escalation of care discussions across our Ageing and Complex Medicine department to 90% by November 2022.

Method: Retrospective review of randomly selected electronic case notes for patients discharged in August 2021, November 2021, March 2022, August 2022 and November 2022, to determine when resuscitation was discussed and, if not discussed, the reasons why. Interventions included: 1. face-to-face presentation of findings with discussion at departmental teaching, 2. distribution of posters on each ward, 3. discussion between each ward team, to review individual wards results.

Results: 388 patient cases were reviewed over 5 data collection cycles. At baseline, in August 2021, 49% patients had discussion surrounding resuscitation, increasing to 69% following intervention 1 (November 2021) and 79% following intervention 2 (March 2022). Follow up in August 2022 showed this increase was not sustained, falling to 64%. After intervention 3 (November 2022) this rose again to 72%. August 2022 data was evaluated to identify reasons behind no discussion. The main reason was 'good baseline' (31.1%) with no documented reason in 48.3% cases.

Conclusion: Percentage of resuscitation discussions has fluctuated over time, improving following targeted intervention but has not reached 90%. The main barriers to success identified included junior doctor change-over, fast patient flow, competing ward priorities and patients'/relatives' lack of understanding. We hope to integrate teaching regarding resuscitation into our departmental induction, to sustain knowledge and understanding within the workforce.

Introduction: Medication non-adherence is estimated to cost the NHS >£500 million a year in preventable morbidity, mortality and health service use. Multi-compartment medication compliance aids (MCAs) are provided in an effort to promote adherence, despite opposing recommendations from NICE and the Royal Pharmaceutical Society. This study aimed to understand the views of patients and carers of MCAs, including those who have declined or discontinued the use of a pharmacy-filled medication compliance aid (pMCA).

Method: A researcher-administered questionnaire survey of older adults (“users”) and carers, who used, declined or discontinued a pMCA. Participants were recruited from inpatient, outpatient and community services at a central London NHS trust. Thematic analysis was conducted by two independent researchers to identify overarching themes.

Results: 88 users and 88 carers were interviewed. The majority of pMCAs were started by healthcare professionals or requested by the carer due to polypharmacy. 12 of 61 users (20%) did not know why a pMCA had been provided, with only 6 requesting the aid themselves. 5 (8%) current pMCA users considered returning to taking medicines from their original packaging. Themes common to both groups included polypharmacy and poor product design. A theme identified solely in the patient group was autonomy and independence, while carers commented on time, waste and sustainability, and responsibility and associated mistakes. For the most part, carers and users perceived MCAs as useful tools to assist medication adherence.

Conclusion: pMCAs are often issued to manage complex medication regimens which are cognitively overwhelming, sometimes at the expense of patient autonomy. Healthcare professionals should aim to reduce the need for pMCAs through individualised medication reviews and rationalisation and improvement of pathways to obtain medicines. If their use is unavoidable, the design of the product and healthcare systems surrounding their use should be optimised to improve the user experience.

Introduction

There is relatively little known about physical health of older people who are unpaid carers. The English Longitudinal Study of Ageing (ELSA) Wave 9 (2019) was used to examine the relationship between unpaid caring and health. This study contains information on frailty, caring, comorbidities and Instrumental Activities of Daily Living (IADL) from 8,736 participants 50 years and over.

Methods

We included participants who received a nurse visit in Wave 9 (n=3,047), 21 were excluded due to missing data. Frailty was calculated using the ELSA-Frailty Index (FI). Carers were those in receipt of Carers Allowance or self-reported unpaid caring.

Results

351 carers and 2675 non-carers were included. Carers were younger (64.5 (10.2) vs 66.7 (10.5), p<.001) and more likely to be married (78.1% vs 62.8%, p<0.001). carers had a lower median fi score (0.07 (0.04-0.14) 0.15 (0.12-0.21), p="0.000)" however, 45 />536(8%) of moderately and severely frail participants were carers. Of 966 non-frail (FI <.12) participants: 9 />246(2.6%) carers experienced difficulties with IADLs, compared to 5/720(0.69%) non-carers; 79/246(31%) of carers had impaired mobility, compared to 39/720(5%) of non-carer; and 51/246(20%) had 2+ comorbidities, compared to 17/720(2.4%) non-carers. Of 1524 mildly frail (FI>0.12-0.24) participants: 16/60(26.7%) carers experienced difficulties with IADLs, compared to 116/1464(0.69%) non-carers; 58/60(97%) of carers had impaired mobility, compared to 807/1464(55%) non-carers; and 42/60(70%) had 2+ comorbidities, compared to 607/1464(41.4%) non-carers. On frailty-adjusted multivariable analysis there was a strong association between carer status and comorbidities with Odds Ratio (OR)3.01 (95%CI 2.21-4.10); impaired mobility, OR 11.08 (95%CI7.52-16.32); and impaired IADLs, OR 5.44(95%CI3.48-8.48)

Conclusions

Carers are less likely to be frail but more likely to struggle with at least one IADL, experience comorbidity or mobility impairment than equivalently frail peers. This suggests that, in the over 50s, either caring contributes to impairment or the burden of care falls on the more impaired.

Introduction
As part of a planned care initiative undertaken with the Bevan Commission to improve surgical waiting lists in Swansea Bay we contacted patients on the waiting list for a cholecystectomy, undertook frailty screening and invited those with frailty markers to undergo clinic based geriatric assessment . Clinical governance requires patient input into the setup of any service (1). A patient satisfaction survey following clinic, along with a patient focus group were conducted. Methods 27 patients completed an online survey regarding their experience at clinic. 8 patients attended the focus group, all had attended clinic. Those we hadn't seen face to face declined or were unable to attend. The group was run by a team who were independent of the project, recorded on teams and transcribed. Results Post clinic survey 100% (27/27 patients) knew why they were invited to clinic, >80% found it useful and 92% felt their health needs were covered. The focus group highlighted a number of issues regarding frustration with administration of the list, feeling ‘forgotten about’ and as though they ‘didn’t matter’. They attended multiple pre-op assessments but had no communication, they felt our clinic was their first meaningful clinical contact.

Conclusions

Patient reported experience is a key part of service development however bias is often evident. (2) It was clear that patients valued the face to face aspect of clinic and the focus group. One clear theme from our focus group highlights administration and communication which are potentially modifiable within our resources. A theme of desiring patient choice and continuity of care between specialities was evident, which we hope to address with a unified pathway for perioperative care. 1) Clinical governance - GOV.UK (www.gov.uk) 2) The use of focus group discussion methodology: Insights from two decades of application in conservation, T O Nyumba. 2018

Introduction
The NHS backlog in Elective Surgery are a subject of societal concern and political pressure. Over 6,400 patients >65 yrs are currently awaiting surgery at Swansea Bay. What role, if any, can geriatricians play in improving patient and organisational outcomes? Intervention We wrote to all 258 patients on the Cholecystectomy waiting list > 65 yrs with a letter explaining the project and a patient experience questionnaire. An attempt to contact all patients by telephone was made with an intention to ask questions about their health, activities of daily living and frailty and complete a CRANE questionnaire. Patients who were identified as frail either by the CFS or HFRS, with complex co-morbidities and any concerns raised by the CRANE questionnaire were offered a clinic appointment. Clinic outcomes were prospectively recorded. Patients who attended clinic were asked about their experience through another questionnaire and focus groups. Results from phase A (January 2023) The waiting list had 258 patients, 193 (75%) patients spoken to on telephone. 32 of these have been seen clinic to date with another 11 due to attend. These clinics have identified spinal wedge fractures, abdominal aortic aneurysm requiring surveillance, potential malignancy (referred for imaging), possible new diagnosis of RA, optimisation of cardiac drugs (5 patients), polypharmacy management, hyponatraemia; amongst others with several patients referred to other frailty or specialist services. This process was able to reduce the waiting list by 36 patients or 14% of those >65yrs on the waiting list. The focus groups and questionnaires showed patients valued the service.

Conclusion
This project demonstrates that proactive management can yield a substantial benefit, both in optimising patients experience and health outcomes and by producing an organisational benefit by reducing the overall waiting list size and allowing anaesthetic led perioperative clinics to function more efficiently.