bluuebunny/crossref_metadata_2025_split huggingface dataset:
17 Improving Frailty Identification and Comprehensive Geriatric Assessment (CGA) Completion on the Wards
Authors: Verma D , Bonora F , Walker R , Kaneshamoorthy M , Bafadhel L 
Published: February 2020

Abstract

Introduction
The Comprehensive Geriatric Assessment (CGA) is known to deliver substantial and measurable health improvements to frail older people, including increased independence and a reduction in mortality.1 The Clinical Frailty Scale (CFS) can detect older adults at higher risk of complicated course and longer hospital stay.2 Despite the known benefits, previous audits has shown poor documentation on geriatric wards at Southend Hospital. Therefore, we devised a Quality Improvement Project to improve the uptake of both these.

Methods
A total of two Plan Do Study Act (PDSA) cycles were completed where CGA completion and CFS documentation was audited. Each cycle lasted two weeks (25 patients). Qualitative feedback was obtained from the members of multidisciplinary team to aid improvements. The baseline audit was based on the introduction of a 2-page ward proforma for all new patients. The first intervention was an improved 2-page ward-proforma. The second intervention was a single page ward-proforma.

Results
Originally, 40% of new patients admitted onto the ward had a CGA assessment and CFS score. After the first intervention, 79% (19) patients had a CFS score and a CGA assessment. 21% had a full CGA completed and 58% had partial CGA. Feedback included wanting a single page proforma to increase uptake. Questions needed to be more unambiguous and more tick boxes. After the second intervention 100% (25) patients had a CFS score and a CGA assessment. 40% (10) had a full CGA completed and 60% (15) had a partial CGA. Feedback include incorporating the ward round documentation to avoid repetition.

Conclusions
The results show that by using a focused, concise and user-friendly proforma, uptake of the Comprehensive Geriatric Assessment and Clinical Frailty Scale can be significantly increased, bringing substantial and measurable health improvements to frail older people admitted to elderly care wards.

References
1. Welsh TJ, Gordon AL, Gladman JR. Int J Clin Pract. 2014;68(3):290–293.
2. Juma S, Taabazuing MM, Montero-Odasso M. Can Geriatr J. 2016;19(2):34–39.
23 Earlier Therapy Intervention in the Emergency Department to Improve Clinical Outcomes for Fallers Aged 65 and Over
Authors: Roberts F 
Published: February 2020

Abstract

Purpose
To improve clinical outcomes for fallers aged 65 and over presenting to the emergency department through earlier therapy intervention and multidisciplinary focussed assessments.
The intended benefits to the older person and service were for:Older adult fallers to be referred more quickly for a therapy assessment.Older adults to spend less time immobile on an emergency department trolley.Timely multidisciplinary discharge plans being formulated in line with national guidelines.Increased numbers of older adults receiving holistic comprehensive geriatric assessments.

Methods
The quality improvement project was carried out using the Plan, Do, Study, Act (PDSA) cycle. Three iterative PDSA cycles were carried out over the course of the project to deliver simple, proactive interventions developed as a result of local baseline data analysis as well as stakeholder and root cause analysis. These interventions were all aimed at increasing the visual presence of the therapy team within the emergency department.

Results
The project resulted in an increased referral speed of fallers aged 65 and over for assessment, which led to increased numbers of older adult fallers receiving holistic, multidisciplinary assessments. 120% more adult fallers were seen in January 2019 compared to the previous year, and 58% more fallers were seen in February 2019 compared to 2018.
The earlier intervention by the therapy team also led to more older adults up and moving sooner, which had positive effects in terms of maintaining their dignity.

Conclusions
The quality improvement project found that more older adults aged 65 and over admitted to the emergency department with a fall can receive holistic, multidisciplinary assessments through the introduction of small, simple interventions aimed at increasing the proactivity and overall visual presence of the physiotherapy team.
The team are providing care to a larger number of older adults, improving their functional independence, dignity and quality of life and giving them an overall more positive experience.
The ED model of care is traditionally nursing and medical led but what this improvement project shows it that it is essentially the collaborative nature of the multidisciplinary team that can lead to better clinical outcomes for older adults attending the emergency department.
31 Understanding of Comprehensive Geriatric Assessment Among Fifth Year Medical Students
Authors: Perera D , Jones A 
Published: February 2020

Abstract

Introduction
There are 191 foundation programme jobs in geriatrics in the North East.1 Students often don’t receive teaching sessions on the comprehensive geriatric assessment (CGA). It is an assessment foundation trainees use on a daily basis on the geriatric ward and the acute take.

Methods
We designed a series of teaching sessions for fifth year medical students, delivered by different members of the multidisciplinary team. A pre- and post-session questionnaire assessed their understanding.

Results
Nine students completed the pre-session questionnaire:22% were able to define CGA11% identified the different components22% identified the target population, the benefits of CGA and the members involved44% offered solutions to obtaining a history from patients with confusion100% identified the barriers to carrying out CGA
Seven students carried out the post session questionnaire; the table below represents the number that answered correctly.

Conclusions
The majority of foundation trainees will have at least one job in geriatric medicine and participate in the acute take. The average age of hospital admissions has been rising for years,2 highlighting the importance of being able to accurately and thoroughly assess the older population. The initial questionnaire demonstrated the limited understanding that fifth year students had on the comprehensive geriatric assessment. Following sessions by different members of the MDT there was clear improvement.
The sessions covered: general overview of CGA; session by the frailty pharmacist; functional assessment by physiotherapy team; cognitive assessment by the dementia and delirium team; and life as an F1 on geriatric medicine. Positive feedback was received, emphasising the improvement in confidence in preparation for foundation training.

References
1. Oriel website: https://www.oriel.nhs.uk/Web/FND.
2. NHS digital Hospital Admitted Patient Care Activity 2015–16.
39 Care Home Liaison Role- Bridging the Gap Between Acute Hospitals and Care Homes
Authors: Sendall C , Wright P , Downes R 
Published: February 2020

Abstract

Introduction
There are over 400,000 people over 65 in UK care homes, three times the number than that in acute hospitals. They are amongst the frailest in our community, with average life expectancy of 15months once in the home. Their needs are often complex and challenging, which when unmet, often result in unwanted and unnecessary hospital admissions.
Imperial College Healthcare Trust (ICHT), along with funding from Health Education England (HEE), have introduced a care home liaison nurse. The aim is to bridge the boundaries, making a significant difference to cross organisation communication and support.

Methods
The care home liaison nurse manages a frailty liaison service with the largest local nursing care home. This home has 140 residents with complex needs. The care home liaison nurse provides a point of contact for advice, guidance and support for individual patient pathways, she provides face to face assessment and treatment or verbal advice. In addition, the nurse supports discharge from the acute setting. This direct contact allows rapid access to specialist advice, and aims to build confidence both within the care home team and within the acute team, that the patients’ needs can be met in their own surroundings.

Results
The preliminary data demonstrates a positive impact this role is having both to the acute trust and most importantly patient’s experience. Comparing ICHT data from April-May 2018 to April-May 2019 it showing that the number of avoidable admissions has decreased from 54.3% to 37.5%, length of stay when patients are admitted has decreased from 11.7 days to 6.5 days, and the number of patients with an advanced care plan has risen 14.9%. Feedback from nursing staff at the care centre as well as that from patients and families has been overwhelmingly positive.

Conclusions
The role is still in the pilot phase. Given the already positive impact it is hoped that it will continue and expand into other care homes and extra sheltered accommodations.
45 Implementing A Frailty at the Front Door Service in the Emergency Department
Authors: McGurn B , McDicken J , McKee H , Docharty D , Duffty A , Bailey M , McCallum G , MacInnes B , Morrow K 
Published: February 2020

Abstract

Background
University Hospital Hairmyres is a small District General Hospital in Lanarkshire Scotland. We have an active Care of the Elderly Department with a well-established Acute Care of the Elderly (ACE) team of Advanced Nurse Practitioners, supported by Consultants. This team delivers Comprehensive Geriatric Assessment (CGA) to frail older people in acute medical receiving as well as offering liaison to medical, surgical and orthopaedic wards.
Local problem and intervention: Our patients were not always being managed by the correct professionals in a timely manner, leading to delays especially in the Emergency Department (ED). We set up a Frailty at the Front Door (FAFD) service to address this, commencing July 2018. Supported by additional consultant sessions, we re-focused the ACE team on assessing and managing frail patients in the ED. The aim was to get the right patient to the right place at the right time and to manage acutely ill people at home where this was safe. Where admission was required we aimed to admit directly to a specialty bed, bypassing acute receiving wards.

Methods
We routinely collect important data including number of frail patients, %patients receiving CGA within 24 hours, number of discharges. To assess the impact of our change we analysed the data by plotting on run charts and statistical process control charts. In addition we assessed the effect on referrals from medical specialties and the number of direct-to-specialty admissions.

Results
After the 22 July 2018 we noticed a significant increase in patients screened for frailty, and a significant increase in discharges. We were able to reliably sustain over 95% of frail patients getting CGA within 24 hrs. There was an increased use of hospital at home. There was a reduction in referrals from medical wards (median = 10/week before, 5/week after intervention). Between August 2018 and May 2019 we were able to admit 163 patients directly to specialty beds. There was no change in re-admission rate.

Conclusions
We successfully changed our service to have consultant delivered Frailty at the Front Door, assessing more frail patients. Most importantly, we have an improved patient pathway, both managing more people at home but also reducing ward moves by achieving direct to specialty admissions. CGA can be safely delivered in the ED.
48 Specialist Physiotherapist Leading in the Frailty Revolution in Ambulatory Emergency Care at the John Radcliffe Hospital, Oxford
Authors: Greensitt B 
Published: February 2020

Abstract

Background
The Ambulatory Assessment Unit (AAU) at the John Radcliffe Hospital aims to provide excellent care for complex patients with varying range of medical presentations. It sees over 50% of the acute take in operational hours, with over 40% of AAU patients over the age of 70. Staff feedback consistently identified a suboptimal service provided to the frail group within this patient cohort. A dedicated physiotherapist specialising in older people living with frailty joined the team in October 2018 to address this.

Aims
Early identification of patients with frailty attending the unit Improve staff understanding of frailty to enhance patient care Assess patients to either enable a patient to return home safely or support ambulatory pathway Refer to community services that can support the patient and enable them to live well after hospital attendance Review the impact of the specialist physiotherapist’s role

Methods
Introduction of frailty identification as per frailty team guidance Frailty questionnaire to ascertain baseline understanding and learning needs to develop staff training Assess patients using a Comprehensive Geriatric Assessment Raise staff and patient awareness of community support services available within the community Data collection to review interventions taken, bed days saved and re-attendance rates

Results
129 new patients were seen in a 4-month period. 85% returned home the same day; 64% had their ambulatory pathway supported with therapy intervention and 21% had an acute admission avoided directly due to therapy. 15% were admitted to an acute bed for safety 60% of patients were referred to community services and 50% were signposted to a range of community and support services The re-admission rates for therapy related reasons within 7 days and 30 days were 0% and 4% respectively. 38 bed days were saved with a calculated cost saving of £15,162

Future service delivery and conclusions
There is ongoing work to obtain patient experience data for those who had their admission avoided directly due to therapy intervention. A training programme on frailty for all members of the MDT is to be developed. A dedicated therapy service in an ambulatory setting has a role in ensuring that patients’ needs are met in the most appropriate place and enhances their quality of life after hospital attendance.
50 Cognitive Assessment of Patients As Mandatory Part of MDT in A Community Rehabilitation Hospital
Authors: Gupta S , Milner S , Shah S 
Published: February 2020

Abstract

Introduction
Undiagnosed underlying cognitive issues have an impact on progression with rehabilitation. Early diagnosis of these is beneficial to the patient as it can offer them early treatment and advance planning for their future care.

Methods
Patients transferred to our rehabilitation wards from other specialities often do not have a routine cognitive assessment done. This has a negative impact on their rehabilitation goals and discharge planning. We hence routinely assessed cognition for all the patients transferred to our rehabilitation unit across two sites for 3 months. In the weekly MDT, we discussed in detail the cognition of each patient, taking into account not only the doctor’s view, but also nursing and therapists. Once a concern was raised, we investigated them fully with blood tests, imaging and MOCA or ACE-R.

Results
56 patients were diagnosed as having cognitive issues. Average age was 81.67 years. Of them 32.14%were from surgical specialities and the rest from other sub-specialities of medicine.
In the MDT cognitive concerns were raised 73.2% by therapists, 66.1%by nurses and 60.7% by doctors.
Of the concerns raised, 87.4% of patients were diagnosed with some form of underlying dementia or cognitive impairment. 55.4% were started on treatment. Remaining was either palliative deemed unsuitable for treatment or needed more detailed input from community psychiatry team on discharge.
75% were for follow up with the mental health team on discharge, 7.14% by the Parkinson’s specialist and the rest by the own GP.
All diagnosis was notified to the patient, next-of-kin and the GP

Conclusions
Routine multidisciplinary approach to cognitive assessment helps us in new and prompt diagnosis of dementia, offer appropriate treatment and plan ahead for the future.
52 A Community Cure for Frequent Reattenders: Developing An Interface Geriatrics Service
Authors: Davies O , James S 
Published: February 2020

Abstract

Topic
Setting up an interface geriatrics service in a seaside area with a large elderly population. Many elderly patients are readmitted due to the challenge of managing their chronic health conditions in the community. These patients are frail, with frequently exacerbated chronic conditions causing regular readmissions. We noted that treatment was rarely changed during these admissions and patients were not uniformly managed.

Aims
Aims for this project were to improve care for older people, reduce readmissions and produce clear patient care plans.

Interventions
Our first PDSA cycle involved implementing geriatrician presence at community MDTs (involving social services, GPs, intermediate care teams, and various others). This generated home visits to several patients, with a mix of acute and chronic issues. We offered Advance Care planning where appropriate to these patients. We noted several patients were repeatedly discussed at MDT. This brought into focus frequent attenders who were usually well-known to the community. In the next cycle we introduced ‘frequent attender’ plans for these patients, ensuring a unified approach to their management. Subsequent cycles involved geriatrician presence at the ‘frequent attenders’ steering group, and further links with community teams. Our primary intervention has been Advance care & frequent attender plans offering tailored management for complex patients. These are completed by a geriatrician discussing patients wishes for treatment and future care.

Improvements
Readmission rates show up to 90% reduction in admissions/ED attendances for patients following care plan implementation. Feedback from families and patients is positive – the service is ‘pragmatic and supportive’, delivering ‘empathetic care’.

Discussion
Implementing an interface geriatrics service highlights the importance of caring for frail patients in their preferred place of care, reducing unnecessary/inappropriate hospitalisations. Geriatrician presence at community MDTs has improved care by offering prompt access to medical advice and review of complex patients. It highlights patients presenting frequently to services, allowing us to work with patients and families to improve management. A frequent attender list generated by the hospital helps target patients for whom intervention will give significant benefit. We plan to extend this further by working with nursing homes that have high conveyancing rates. The service is being extended to more areas within our region, and we are working with GPs and care homes to further offer advance care planning to vulnerable and frail patients.
54 A Quality Improvement Project on the Recording of Stool Charts
Authors: Perera D , Kaneshamoorthy M , Burdon Z , O'Brien A 
Published: February 2020

Abstract

Introduction
Change in bowel movement is a common complaint in frail patients, which can be indicative of conditions such as constipation, infection or malnutrition. Without prompt action, this can result in increased length of stay. The recording of stools can be variable. This quality improvement project was to improve stool chart completion rate and staff confidence.

Methods
We conducted two Plan-Do-Study-Act cycles over three months. We surveyed multidisciplinary staff confidence using Likert scales covering each element on the Bristol stool chart. We then reviewed patient stool charts. The first intervention was a poster. The second intervention was the addition of a sticker to the charts to help staff more easily identify them in the patient’s bedside notes. Staff-wide emails were sent to inform every one of the interventions and key stakeholders including ward managers were asked to hand this over.

Results
44 multidisciplinary staff were interviewed and 217 individual stool charts assessed over a 3 month period. 43% of stool charts were not filled in as directed after the first cycle. Posters improved staff confidence in filling out the charts from 72.3% to 92.3% after the second cycle, while 61% of stool charts came to be filled in correctly - over the initial 57%. Healthcare assistants consistently scored the highest in terms of believing charts to be up to date being whereas doctors remained the most cynical. There was little sustained change in stool chart completion rates after three PDSA cycles. Eventually, after both interventions, completion rates returned to baseline.

Conclusions
Stool chart completion rates can be improved in the short term, but sustainability is a challenge. Factors contributing to this include the variable number of agency nurses. Further improvements include teaching at the nursing induction.
56 Quality Improvement Project on the Bowel Charts in An Elderly Care Ward in Basildon University Hospital
Authors: Hakim R A , Ali M , Wijenyake I 
Published: February 2020

Abstract

Background
To improve the rate of documentation on bowel charts on an elderly care ward with a significant percentage of patients suffering from dementia.

Importance
As a junior doctor working on an elderly care ward with patients who often had memory problems and were unable to recall their bowel patterns, it was extremely challenging to establish whether a particular patient has constipation or diarrhoea.
Constipation in an elderly patient can lead to multiple complications like urinary retention, intestinal obstruction and often decreased oral intake.

Methods
An audit was carried out to see the rate of completion of the Bowel charts on the ward.
Only about 23% of the bowel charts on the ward were complete in the initial survey.
Then interventions were introduced in steps and three more audits were done.
At each step, we were able to show how the interventions introduced changed the degree of completion of the bowel charts.

Outcome
We have seen a marked improvement of 37% since the start of the project 5 months ago. From 23% to 60% completion of bowel charts.
There appeared to be a sustained change only falling short at the weekends (due to staffing issues)
Overall awareness had increased vastly.
We were able to make a measurable change and improvement in the quality of care provided.