bluuebunny/crossref_metadata_2025_split huggingface dataset:
1190 QUALITY IMPROVEMENT PROJECT ON MEDICAL DISCHARGE LETTERS
Authors: Wee K C , Alicehajic-Becic D 
Published: January 2023

Abstract

Introduction
The aim of this quality improvement project was to assess the medical discharge letters written by medical colleagues at this trust against the guidelines set by the Royal College of Physicians. The target was to achieve at least 90% compliance across the components evaluated at the end of this project.

Method
This quality improvement project evaluated medical discharge letters from three medical wards. Following the application of filtering criteria, a sample size of approximately 20 patients was randomly selected for data collection. Sections that were evaluated in the discharge letter included areas of clinical summary information, investigative results, medication changes, follow-ups and GP actions. Information obtained from the letters were reported as ‘yes’, ‘no’ or ‘non-applicable’ on an Excel spreadsheet. Data collected was analysed and areas of strengths and weaknesses were identified. They were used to form action plans, following which the cycle of evaluation was repeated.

Results
Two cycles were carried out in this project. Issues were identified in the sections of clinical summary, documentation of blood results, medication changes and their indication, and follow-ups. Action plans such as education (leaflet, emails and education session), introduction of a discharge letter checklist and acronym expansion were used. By the end of the third round of data collection, all components achieved at least 90% compliance, with the exception of changes in regular medications and differentiation of follow-ups into booked and those which needed booking.

Conclusion
This project has resulted in an increase in adherence to the standards set by the College when completing medical discharge letters. Periodic evaluation will be beneficial to ensure that a high standard of compliance is consistently achieved. Sample size could be increased to improve the significance of evaluation. This study can be expanded to other specialties to increase coverage.
1271 A NOVEL PRESSURE INJURY CARE BUNDLE FOR DEPENDENT PATIENTS WITH PRESSURE INJURIES IN BERMUDA
Authors: Myint H , Simmons M , De La Cruz J , Diaz B , Baldonado G , Edwards B , Kiriyadoss D , Drummond K , Mulkerrin E C 
Published: January 2023

Abstract

Introduction
Pressure injury (PI) management is a challenge in dependent patients in acute care wards (ACW) despite standard care (regular pressure relief measures, incontinence management, debridement, optimisation of hydration and nutrition).

Method
A Pressure Injury Care Bundle (PICB), introduced by the Department of Geriatrics, enhanced standard care by diligent and regular interdisciplinary team monitoring of patients with PIs following transfer to Long Term Care (LTC) wards and thus may improve outcomes. The PICB was delivered by multiple PI Nurse Champions with education of all nurse assistants and medical staff into PI aetiology/management. Progress was monitored with weekly PI measurements/photography and Nurse Champion-lead team review of all PIs. Data are presented as mean+/-1SD. After 96+/-103 days in the ACW, the PICB was applied to 30 consecutive patients aged 80+/-14 years, (19(60 %) were female). All had stage 2-4 PIs (present in 25(83%) on admission to ACW). On transfer to LTC wards, all patients had severe physical dependency with a mean Charlson Comorbidity Index of 7+/-3, 27(90%) had palliative needs and 24(80%) were bedfast. Cognitive impairment was present in 22(68%) patients with 12(37%) dying due to advanced dementia. Patients were followed for 116+/-274 days.

Results
PI improvement by &gt;2 stages occurred in 11(36%) patients after a mean of 103 days. Ulcers closed fully after 154+/-48 days in a further 15(50 %) patients. However, new ulcers emerged or preterminal (&lt;21 days prior to death) deterioration occurred in 5(17%) patients, related to severe contractures, preterminal poor nutrition and sarcopenia with 16(54%) patients dying.

Conclusion
These results suggest that an intensive multimodal intervention involving best practice enhanced by PI Nurse Champions and delivered by educated staff with regular PI team progress reviews results in significant improvement/healing of PIs in severely dependent patients with palliative needs. Expansion of the PICB to other wards with prospective evaluation has been planned.
1304 LAXATIVES PRESCRIPTION MONITORING FOR AN OVERLOOKED PROBLEM
Authors: Wong E , Payab Q , Justin J , Nadir R , Aung N , O’Malley F , Gamble E 
Published: January 2023

Abstract

Introduction
Constipation is a common diagnosis among hospitalized patients. It results in considerable morbidity in elderly patients, healthcare utilization and economic burden. Laxatives are commonly prescribed but poorly monitored due to benign side effect perception.

Aim
We undertook a review of the quality of laxative prescribing and subsequent monitoring amongst an inpatient cohort. We propose new standards:
- Medication review at least once weekly;
- Documented rationale for choice of medication
- Specified timeframe review and outcome documentation
We reviewed current hospital trust policy of laxative prescribing and produced a new constipation management guideline in response to early audit data.

Method
Data collected across medical wards in Trafford General Hospital, Manchester. Data was collected on types of laxatives, reason for prescription, date of review, length of course, compliance and effect of laxatives. Two rounds of audit were performed 6 months apart, with an interim intervention of staff education and local introduction of a new constipation management guideline. The guideline consisted of decision algorithm and suggested treatment.

Results
47 individual prescriptions were audited in round 1 and 72 prescriptions in round 2, this represented 23 and 32 patients respectively. Review of medications within first week of prescription improved from 17% to 83.7% across the two cycles. Documentation of constipation diagnosis improved from 52.2% to 97.2%. There were large percentage improvements in documentation of specified treatment outcomes across all audited fields, despite overall poorer medication compliance among patients in round 2 (56.9% versus 66% in round 1). The average length of laxative use decreased from 18.6 days to 15.3 with overall percentage of patient with constipation resolved increased from 65% in round 1 to 73% in Round 2

Conclusion
Staff education and implementation of treatment guidelines made a substantial improvement to the medical management of constipation in hospitalized patients.
1307 IMPLEMENTING THE HEE COMPREHENSIVE GERIATRIC ASSESSMENT (CGA) FOR FALLS IN CARE HOME PATIENTS– A QUALITY IMPROVEMENT PROJECT
Authors: Jones K , Tekkis N , Dronfield S , Munslow N 
Published: January 2023

Abstract

Introduction
According to the Health Education England (HEE) Framework for Enhanced Health in Care Homes 2020, 33% of people over 65 and 50% of people over 80 have one or more fall a year, figures which significantly increase in care home residents. Prevention of falls promotes the quality of life of elderly patients and could significantly reduce the burden on primary and secondary care stemming from fall induced fractures, loss of mobility and community follow up. The Comprehensive Geriatric Assessment (CGA) for falls includes a full falls assessment questionnaire, medication review, lying/standing blood pressure and frailty index. The HEE set out a requirement that all care home patients should have a CGA assessment within 7 days of readmission to a care home following a hospital episode because of a fall. This audit examined the compliance of Four Counties primary care network (PCN) to the 7-day CGA HEE guideline for falls.

Methods
Retrospective analysis of 68 eligible patients from Four Counties PCN between 31st March 2021 and 1st March 2022. Analysis indicated a poor compliance to the HEE CGA guidelines (15%). After presenting to the MDT, we formulated a system-wide plan to improve reporting of care home falls to OTs, creating protected time for pharmacists to conduct care home medication reviews and promoting in-person weekly care-coordinator meetings. The PCN was audited for a second time after 3 months.

Results
A significant improvement (15% to 57%) in adherence to the HEE CGA framework was noted after implementation of above changes. Medication review in 7 days improved from 42% to 80% and falls assessment questionnaire in 7 days compliance improved from 23% to 70%.

Conclusion
Creating clear protocols for reporting falls and clarifying MDT roles in the CGA are essential to identifying and preventing falls in at-risk care home residents.
1326 IMPROVING THE QUALITY OF BOWEL CARE ON GERIATRIC WARDS BY INCREASING COMPLIANCE OF DAILY DOCUMENTATION OF BOWEL MOTIONS
Authors: Bamgboye J , Mithani P , Bafhadel L , Whitear J , Kaneshamoorthy M 
Published: January 2023

Abstract

Introduction
Bowel health is affected in acutely admitted patients due to illness, change in diet, dehydration, and reduced mobility. Constipation is common and older patients are particularly at risk of constipation due to reduced bowel transit speed. Bowel motion monitoring can help improve bowel health and reduce complications including delirium, which can prolong hospital admission. To increase detection of constipation, a quality improvement project was carried out in the Department of Medicine for the Elderly at Southend Hospital, with aims to increase compliance of daily stool chart entries. Early detection will prompt patient review, investigation, and treatment of constipation, thereby managing symptoms and preventing complications.

Method
Stool charts of patients across the geriatric wards were reviewed weekly for daily entries up to the last 7 days of their admission. Baseline compliance was determined on day 0 by dividing total days of stool chart entries over total days of admission (up to 7 days). Patients newly admitted or transferred to the ward on the day of stool chart review were excluded from the data. Interventions included verbal reminders to stakeholders (nurses, HCAs, doctors) at morning handovers, an electronic reminder with emails to stakeholders, and lastly a visual reminder with copies of a poster around the ward. The interventions were implemented separately on a weekly basis to quantify their effectiveness on compliance through further stool charts reviews on days 7, 14 and 21, and compared to baseline data.

Results
Overall compliance increased by 16.9%, and the largest improvement was in response to the poster strategically placed next to all patient charts.

Conclusion
The QIP was time and resource efficient, helping to identify constipation early and flag patients at risk for or for treatment of constipation. It is also easily repeatable and similar principles can be applied across other wards and specialties.
1339 IMPROVING INPATIENT MANAGEMENT OF DELIRIUM IN A DISTRICT GENERAL HOSPITAL
Authors: Juwarkar A , Ahmed S , Franks S , Ring A 
Published: January 2023

Abstract

Background
Delirium is a common clinical condition associated with increased morbidity and mortality, and prolonged hospital stay. Early detection is vital to improving management of the condition and improving outcomes.

Aims
Improve delirium detection using the 4AT screening tool as a validated approach; Improve delirium management across multiple domains using the PINCH ME approach; documented attempt at collateral history within 24 hours of recognition of delirium; obtain serological confusion screen in patients with recognised delirium. (100% each)

Method
Plan Do Study Act (PDSA) method was used to conduct this Quality Improvement (QI) project over 12 months. Data was obtained from paper and electronic records in the medical wards with regards to 'at risk patients' (i.e. over 65y, acutely unwell, background of cognitive impairment and/or acute fracture). The use of 4AT or alternative delirium screens from the emergency department (ED) and medical teams were noted. Assessment for pain, urinalysis, serological screens, bowel and nutrition review including MUST scores, medication reviews were looked for. Interventions included presentation and education at the medicine grand round, publishing a poster, and a PINCHME alert sticker for the medical notes to use at time of assessment. 2 PDSA cycles were completed and post sticker results obtained.

Results
Baseline data shows that collateral history was attempted for 70% patients - improved to 100% after sticker use. Use of validated screening test from 15% to 100% after sticker use. Nutrition assessment improved from 15% to 40%. Serological testing improved from 40% to 53%. 100% patients received a medication review after sticker use.

Conclusion
Introduction of PINCHME sticker serves as a prompt to ensure holistic management. Currently delirium management is clinician dependent as there is lack of formal delirium management pathway. Further plan includes involving nursing staff and 'delirium champions' to bring about a formal pathway for lasting change.
1292 MEDICALLY SAFE FOR DISCHARGE (MSFD): REDUCING DOCTOR INPUT IN MSFD PATIENTS ACROSS GERIATRIC MEDICINE WARDS AT A DGH IN SOMERSET
Authors: Parker H , Asher G 
Published: January 2023

Abstract

Introduction
Large numbers of geriatric inpatients within acute settings are deemed medically safe for discharge (MSFD) but stranded within the hospital due to a lack of community services and social care packages, leading to increasing length of patient stay and reduced hospital flow. These patients do not require inpatient care and would otherwise be discharged to their home or residential care. This project aimed to identify these patients and rationalise their medical input to mirror a community setting (without routine daily medical reviews).

Methods
MSFD patient were identified by the multi-disciplinary team (MDT). Patients identified received standard nursing and therapy input, alongside daily MDT discussion at a board round to progress discharge planning. If the MDT expressed concern about a MSFD patient, they would receive a medical review. A sticker placed in the notes identified patients deemed MSFD.

Results
A 3-week trial on a 19-bedded geriatric ward showed 46% of bed days were occupied by MSFD patients. On average, 8 MSFD patients did not require daily review. 0.6 unplanned reviews/day were needed due to MDT concern, saving an average of 7.4 patient reviews/day, equating to 3.3 hours/day doctor time saved.

Conclusions
Doctor time saved allowed redistribution of staff to busier wards with more unwell patients, with no detriment to patient care noted. The trust formalised a SOP and the MSFD pathway was introduced across the geriatric medicine department. A MSFD ward has now been opened, to cohort patients awaiting discharge to community pathways. This ward should require minimal doctor input to allow continued redistribution of medical staff across the hospital, as well as facilitating patient flow by admitting patients who reside on the acute frailty unit who require increased community care.
1293 A MULTIDISCIPLINARY TEAM DERIVED QUALITY IMPROVEMENT PROJECT TO IMPROVE THE EFFICIENCY AND EFFECTIVENESS OF THEIR HYBRID MEETING
Authors: Scaife J , Walters E , Fisher N , Kumar S 
Published: January 2023

Abstract

Introduction
Working in a small district general hospital in Llanelli, West Wales, a weekly hybrid multi-disciplinary team (MDT) meeting is held on the stroke and care of the elderly unit. There are 3 separate geriatric teams covering the ward. Typically, these meetings are attended by physiotherapists, occupational therapists, speech and language therapists, discharge nurses, social workers, nurses and a doctor. The main agenda is to discuss the patients’ current medical issues, rehabilitation needs and likely discharge destination/complexities. Medically, these meetings were attended by a single doctor who often found it difficult to concisely summarise the patient’s medical problems from the notes of patients not under their care. Our aim was to streamline the MDT meeting with regards to quality of content, understanding of patient issues and general efficiency.

Intervention
An initial questionnaire was used to gather prospective data. 90% of MDT members suggested that a doctor from each team should attend to present patients under their care and engage in onward discussions. This was implemented over the period of a month. A follow-up questionnaire collected quantitative data by asking MDT members to retrospectively rate, on a scale of 1 to 10, the efficiency of the meeting and the understanding of patient’s medical conditions before and after implementing the change.

Results
The average efficiency was rated at 4.8/10 before the change was implemented and 8.8/10 afterwards, a 40% improvement. Understanding of patient medical issues had a 28% improvement, from an average rating of 6 to 8.8. Qualitative and free text data was also collected highlighting a secondary benefit of reciprocal communication between the therapy MDT and the appropriate medical doctors hopefully improving the timeliness of any required action.

Conclusions
Suggestions of further changes include making the meeting fully face-to-face, providing a “proforma” to document what was discussed and introducing other members of community teams.
1282 EVALUATION OF THE IDENTIFICATION BONE HEALTH OF PATIENTS ON GERIATRIC WARDS
Authors: Amoah J K , Than H P , Phyu E E , Kaneshamoorthy M 
Published: January 2023

Abstract

Introduction
NICE guidelines state that fracture risk assessment should occur in all women aged ≥65 and all men aged ≥75. This includes assessing patients’ FRAX score, measuring serum vitamin D and calcium levels. Early detection and treatment can prevent complications like fragility fractures. We conducted a Quality Improvement Project to improve bone health assessments on Geriatric Wards.

Methods
A baseline audit assessed: admission reason, falls history, FRAX score, CFS, previous DEXA scans, whether vitamin D and calcium levels were checked during the admission, and if treatment was commenced (bone resorption medication and vitamin D/calcium supplements). Data was collected two further times following interventions over a 5-month period. The first intervention was an announcement at the morning departmental meeting reminding clinicians. The second intervention was an email reminder.

Results
There were 56, 51, and 58 patients per cycle. 19, 15, and 17 patients were admitted with falls. 23, 14, and 10 patients had a falls history. Average CFS was 5.4, 5.4, and 5.5. Average major osteoporotic fracture FRAX score was 15.8, 16.4, and 12.9. Checking serum calcium was 88%, 100%, and 100%. Checking vitamin D was 30%, 43%, and 60%. 28%, 43%, and 47% of patients were prescribed calcium and vitamin D supplements. Patients on bone resorptive treatment dropped from 7% to 3% to 2%. 8, 12, and 11 patients had a previous DEXA.

Discussion
Verbal announcement had the greatest impact. Visible reminders help sustainability. This QIP highlighted the lack of bone protection treatment with multiple contributing factors including some patients lacking the capacity to follow instructions to take weekly medications or patients requiring vitamin D being replaced initially, with initiation later. This QIP feeds into a larger trust project in developing a ‘Fracture Liaison Service’, which could improve adherence and provide a pathway in utilising annual and bi-annual treatments.
1192 FALLS PREVENTION: COMMUNITY EXERCISE PROGRAMME; REDUCING RISK OF FALLS, DECONDITIONING AND LONELINESS IN FRAIL ELDERLY PATIENTS
Authors: Butler J , Shalev Greene L 
Published: January 2023

Abstract

Introduction
Covid has had a devastating effect on the Elderly, resulting in deconditioning, increased falls and loneliness. Tailored exercises can reduce falls in people aged over 65 by 54% and participation in physical activity reduces the risk of hip fractures by 50%, currently costing the NHS £1.7 billion per year in England. This 8-week intervention delivered by trained volunteers in patient’s homes, aims to reduce deconditioning, loneliness and the risk, incidence and fear of falling (FOF) amongst frail patients post-discharge from hospital.

Method
A gap in service was identified in Frail patients discharged from hospital, at risk of falling and awaiting community physiotherapy. A steering group was set up including acute and community therapists, volunteers and carers to design a collaborative intervention to bridge the gap. At risk patients were identified and referred by ward therapists supported by the hospital volunteering team. Volunteers were trained to deliver an 8 weeks programme of progressive exercises in patients’ homes with additional signposting to appropriate statutory and voluntary services. Qualitative and quantitative outcome measures were taken at week 1 and week 8 of the intervention

Results
91.5% total health outcomes improved or maintained by average:
- FOF reduced by 22.5%
- 180 degree turn improved by 43%
- 60 sec Sit to Stand improved by 14.75%
- Timed Up And Go improved by 15.5%
- Confidence to cope at home improved by 15%
- Pain / discomfort (self-reported) improved by 18.75%
- Overall health (self-reported) improved by 8.5%

Conclusion(s)
Targeted exercise at home with skilled volunteers can improve functional fitness and health outcomes in a frail elderly population at risk of falls when discharged home from hospital. The programme increases patients’ connectivity to local voluntary and community sector services. Volunteers’ mental health improves by engaging in meaningful service.
1231 MANAGING THE DETERIORATING PATIENT IN A REHABILITATION HOSPITAL: THE ROLE OF TREATMENT ESCALATION PLANNING
Authors: Brown R , Connelly H , McCrae K , Manners R , Waddell G 
Published: January 2023

Abstract

Introduction
The pandemic has shown how vital patient-centred treatment escalation planning (TEP) is for older people. Locally we have seen inappropriate transfer of dying patients to acute hospitals from rehabilitation units. Mortality review found a lack of useful TEPs in these cases. Baseline data in our rehabilitation hospital showed 54% of patients had a TEP and 16% a decision made about repatriation during acute illness. We aimed to increase the proportion of patients in this setting with a TEP to 80% over six months.

Methods
A multidisciplinary team of doctors, ANPs and senior nurses worked together. We conducted stakeholder engagement to understand the factors that result in transfer of patients and found that completion of TEPs was felt to be an effective way to improve communication out of hours. Our first test of change involved an ANP raising the CPR status and TEP for all new patients at the weekly MDT. We measured the process of what decisions were made once a fortnight. Outcome data on the overall completion of TEPs and repatriation decisions was collected each month.

Results
New decisions were made at each MDT – for example, on one date two new DNACPRs and six new TEPs were completed. Overall TEP completion rate varies however since our first intervention we have seen a sustained increase in the number of TEPs which include consideration of repatriation – from 16% to 60%. Ongoing conversation with doctors in training reveals challenges with ward staff awareness of TEP content and their ability to guide unexpected events out of hours.

Conclusion
Involvement of motivated permanent staff across disciplines has allowed us to ensure escalation plans are being made each week and see a sustained increase.