Elderly Wards Research Articles

Optimizing Opioid Prescriptions in Geriatric Populations at Nottingham University Hospitals Foundation Trust (NUH)

Abstract Background Severe pain is associated with adverse outcomes in the geriatric populations (Ref -Pain and Mortality in Older Adults: The Influence of Pain Phenotype - PubMed (nih.gov)). Currently it is recommended in local and national guidelines (Ref -Guidance on the management of pain in older people | Age and Ageing | Oxford Academic (oup.com), Clinical Guidelines Policy (koha-ptfs.co.uk)) that the following be implemented to geriatric patients being prescribed strong opioid medication Methods A multi-disciplinary team involving doctors, pharmacists, nurses and the NUH quality improvement team was involved in all aspects of this project. Initial data collection was done between 1st August 2023 to 1st March 2024. We intend to carry out further data collection between April and August 2024 after our proposed interventions. Data collection was carried out using the EPMA prescribing platform. Results Data collected from 1st August 2023 to 1st March 2024 only 70% of patients in health care of the elderly (HCOE) wards had correctly prescribed oxycodone as their strong opioid analgesia. It was noted that 37% of HCOE patients have had morphine incorrectly prescribed at least once during their admission. Only 11% of strong opioid prescriptions on HCOE wards in NUH had a review scheduled. A. Whilst 73% of patients had laxatives co-prescribed only 25% had anti-emetics co-prescribed. Conclusion From our initial results there is an obvious need for improvement in terms of guideline adherence. We will aim to collect further data and we will put into place interventions in a ‘PDSA’ manner to improve this.

2326 Improving recording and documentation of lying standing blood pressure In patients > 65 admitted with/At high risk of fall(s)

Abstract Introduction The World Falls Guideline 2022 recommends that measurement of lying-standing blood pressure (LSBP) is an integral part of the multifactorial falls assessment (1). Pre-intervention less than half of eligible patients had a LSBP recorded and documented. The aim was to improve the recording and documentation of LSBP for adults aged 65 and over admitted with a fall or at high risk for falls. Method All patients aged 65 and over admitted with fall or identified as at high risk for falls to a care of the elderly ward were included over the period of 15th September 2023-15th November 2023. Royal College of Physicians (RCP) guidance (2017) for standard measurement of LSBP was used2. Data was collected on electronic spreadsheets from electronic observation charts. Two plan do study act (PDSA) cycles were conducted. Firstly, ward posters demonstrated how to record and document LSBP. Secondly ward-based one-to-one teaching interventions using RCP LSBP lanyard flashcards (2) were conducted. Results Following cycle one, 50% of eligible patients had LSBP documented. Following cycle two, 80% of eligible patients had LSBP documented. Following two PDSA cycles, there was a 37.1% increase in the average number of eligible patients who had LSBP correctly recorded and documented. Conclusion(s) Interventions of aide memoirs and education for nursing and medical staff improved the recording and documentation of LSBP. Indications and correct measurement guidance for LSBP should be included in future ward staff induction information and departmental teaching sessions. References 1) Montero-Odasso, M, Van der Velde N, Martin FC et al. The Task Force on Global Guidelines for Falls in Older Adults, World guidelines for falls prevention and management for older adults: a global initiative, Age and Ageing, Volume 51, Issue 9, September 2022. 2) Measurement of lying and standing blood pressure: A brief guide for clinical staff. 2017. https://www.rcplondon.ac.uk/projects/outputs/measurement-lying-and-standing-blood-pressure-brief-guide-clinical-staff.

Is malnutrition screening and risk assessment being conducted according to NICE guidance for patients admitted to care of Elderly wards in Kettering General Hospital?

Is malnutrition screening and risk assessment being conducted according to NICE guidance for patients admitted to care of Elderly wards in Kettering General Hospital?

2015 Identifying and Managing Visual Impairment in Older Patients with Falls on a Care of the Elderly (COTE) ward

Abstract Introduction In 2019, the Royal College of Physicians (RCP) advised that all patients should have their vision screened if identified as a falls risk. Our aim was to implement a bedside visual screening test and establish an onward inpatient referral to Hospital Eye Services (HES). Method This is a collaborative Quality Improvement project involving Geriatric Medicine, HES and the Royal National Institute of Blind People (RNIB). A pilot study cross referenced falls admissions with previous known ophthalmic data to estimate the proportion of known vision loss in this group. In the second phase of the project, a bedside visual screening test has been introduced for all patients admitted to COTE with a fall. Patients failing the screening are reviewed by an RNIB Eye Clinic Liaison Officer (ECLO) and if necessary, a prompt inpatient HES review is arranged. Results Of 182 patients admitted following a fall, in the pilot study, 112 (61%) were known to ophthalmology previously. Of patients known to ophthalmology, 28 (25%) had vision of 6/18 or worse and would be considered to struggle with daily living tasks. 12 (10%) had a certificate of visual impairment (CVI) and 3 (3%) were eligible for CVI but had not been previously registered. One year following implementation of bedside vision testing, 287 patients had been reviewed after failing bedside screening. 97 of these had an onward referral sent or an intervention performed. The first ‘COTE ECLO’ post has been funded as a result of this work. Conclusion Assessing vision is a critical element of the assessment of patients with falls. Through collaboration with the RNIB and Ophthalmology a successful pathway has been developed to address visual impairment in this vulnerable group of patients.

1721 Enhancing the recognition of sensory impairment on the Care of the Elderly wards

Abstract Introduction Although hearing loss is the foremost cause of years lived with disability in people over 70, it remains commonly under-recognised. Health of the UK signing deaf community is reportedly worse than the general population, often due to resulting undertreatment of associated co-morbidities including visual impairment, falls and dementia. Local Problem There is an estimated 21% prevalence of ≥25dBHL hearing loss within the Wolverhampton adult population, this increasing with age. A large number of inpatients admitted to the Older Adult Medicine (OAM) wards at New Cross Hospital have clinically evident sensory impairment, impacting upon interactions with healthcare staff. This project identified the current methods through which hearing and/or visual impairment is formally screened for and documented within the OAM Department of a large district general hospital, targeting interventions towards mitigating barriers faced in sensory assessment. Methods and Intervention Baseline and post-intervention documentation of sensory impairment was collected from admission and bedside notes of 23 inpatients during each cycle. A multidisciplinary focus group of medical, nursing and practice education facilitators identified a marked underutilisation of bedside alert signs (4%), prompting creation of a redesigned bedside poster with a greater focus on sensory aid functionality. Results 60% of posters were utilised 10 days after introduction, with an increase from 4% to 36% in recording of known sensory impairment being observed. 100% and 25% of inpatients with correctly functioning hearing aids and spectacles were documented respectively. 100% of patients admitted through frailty intervention streams were assessed for sensory loss, compared to 0% admitted via the unselected medical take. Conclusions Improved bedside alert posters provided initial evidence as a sustainable improvement in supporting inpatients with sensory impairment. Incorporating positive lessons from frailty team practice will assist in developing future education sessions, highlighting intended sign usage and transferrable sensory assessment methods for involved healthcare teams.

1868 Eight to Hydrate: Promoting oral hydration of elderly patients in hospital

Abstract Introduction Dehydration is associated with prolonged hospital admissions and complications. Elderly patients are more susceptible due to physiology, dexterity and cognition. The British Dietetic Association recommends minimum 7 beverages per day whilst The British Nutrition Foundation advises proactive dehydration risk management in hospital. This project aimed to reduce the proportion of elderly patients at risk of dehydration in hospital. Methods Staff documented oral hydration over 24 hours for patients on the Care of the Elderly ward. Additional factors obtained retrospectively included demographics, dementia diagnosis, fluid prescriptions and fluid restriction. Criteria adapted from a ‘Hydration Care Assessment Tool’ defined risk of dehydration by daily intake as low (>1500mls), medium (800-1500mls), high (400-800mls) or very high (<400mls). Approximating each drink as 200mls, we set a daily target of 8 beverages; equating to low risk. Visual hydration trackers were placed at patients' bedsides and junior doctors reminded the multi-disciplinary team each morning. Data collection was repeated after 2 weeks. Results First cycle recruited 13 males, 16 females with mean age 78.5. Over 50% were Very High Risk (5/29) or High Risk (12/29) of dehydration whilst the remainder were Medium Risk (10/29), or Low risk (2/29). 4/5 (80%) at Very High Risk received intravenous fluids. Of the High-Risk group, more than half had a diagnosis of dementia and 3/12 (25%) received fluids intravenously. Following intervention, 12 males and 7 females were recruited with mean age 76. Proportion at highest risk was reduced: Very High Risk (5/29 to 0/19; -100%), High Risk (12/29 to 3/19; -61%). Therefore, more were at Medium Risk (10/29 to 13/19; +101%) and Low Risk (2/29 to 3/19; +131%). Conclusion Though improved, few patients meet hydration recommendations. However simple visual reminders are an effective starting point. Further interventions could include oral fluid prescriptions and reflect staff and patient feedback.

Improving Parkinson's Medicine Administration in Hospitals: The Impact of an Out-of-Hours Drug Box.

Background Parkinson'sdisease (PD) is a progressive neurodegenerative condition characterised by the loss of dopaminergic neurons and the presence of Lewy bodies. PD medications, notably Levodopa, are critical in controlling patients' symptoms and improving their quality of life. These medications are time-critical, and a delay in administration can have a negative impact on a patient's mobility, quality of life and symptoms. Objective The objective of this quality improvement project (QIP) was to (1) determine the occurrence and underlying factors contributing to delays in PD medication administration at Huddersfield Royal Infirmary and (2) evaluate the impact of subsequent interventions in improving the administration of time-critical PD medications. Methods A total of 20 patients were recruited from Ward 5, a care of the elderly ward, at Huddersfield Royal Infirmary for the entire duration of this QIP; 10 in the pre-intervention phase and 10 for the post-intervention phase one month following the implementation of three interventions: 'Parkinson's Drug Box', ward-based teaching and a hospital-wide screensaver reminder. Datawascollected from the electronic patient record (EPR) to determine and compare the following measures before and after the interventions: the percentage of PD medications administered within the 30-minuterecommendedwindow, the admission-to-medication reconciliation time, scheduled-to-actual dose administration time, and factors causing delays. Results Following the implementation of three interventions, the percentage of patients receiving PD medications within the recommended 30-minute window doubled, increasing from 10% to 20%. Moreover, the average delay in patients receiving their initial PD medication dose decreased from 7.8 hours to 3.7 hours. The percentage of patients experiencing medication delays due to stock shortages also dropped from 50% to 10%. Conclusions Earlier medicines reconciliation and the availability of time-critical drugs out of hours are both key factors in helping to ensure PD medication is administered on time in hospitals. Staff education and a 'Parkinson's Drug Box' are two relatively simple measures that have resulted in improved outcomes for Parkinson's inpatients.

Conversation Analysis Based Simulation (CABS): A method for improving communication skills training for healthcare practitioners.

Actors portraying simulated patients are widely used in communication skills training in healthcare, but debates persist over the authenticity of these interactions. However, healthcare professionals value simulation-based training because of the opportunity to think and react in real time, which alternatives cannot provide. To describe a method for the use of simulation which maximises authenticity by grounding training in real, observed, patterns of patient communication. Naturally occurring care interactions were video recorded and analysed using conversation analysis (CA) to identify communication patterns. We focused on sites of recurring interactional trouble as areas for training, and identified more and less effective ways of dealing with these. We used the CA findings to train actors portraying simulated patients, based on the observed interactional patterns. Patients living with dementia and healthcare practitioners (HCPs) on two acute healthcare of the elderly wards in the English East Midlands. One month later HCPs reported using the skills learned in clinical practice. Masked-ratings of before and after simulated patient encounters confirmed these self-reports in relation to one key area of training. The Conversation Analysis Based Simulation (CABS) method used in this setting showed positive results across a range of quantitative and qualitative outcome measures. What is significant for the transferability of the method is that qualitative feedback from trainees highlighted the ability of the method to not only illuminate their existing effective practices, but to understand why these were effective and be able to articulate them to others. While the CABS method was piloted in the dementia care setting described here, it has potential applicability across healthcare settings where simulated consultations are used in communication skills training. Grounding simulated interaction in the observed communication patterns of real patients is an important means of maximising authenticity. The VideOing to Improve dementia Communication Education (VOICE) intervention which piloted the CABS method was developed by a multidisciplinary team, including three carers of people with dementia. People living with dementia were involved in the rating of the before and after video simulation assessments.

Identify the most effective elderly preventive falling interventions using MCDM technique

Aims A balance disorder is prevalent in older people who cause psychological problems and physical injuries. According to the financial, time, and human resource limitations for developing an elderly rehabilitation ward, this study aims to identify the most significant preventive falling interventions in older population by using the Multi-Criteria Decision Making (MCDM) method to allocate resources to the most effective preventive interventions. Methods First, through the literature review all effective balance interventions were extracted then panel discussion, the Delphi method, and the best-worst method (BWM) was employed to prioritize the preventive falling interventions. Results The result showed that the most significant preventive falling interventions were Neurofeedback (N1), Tai chi (D1), and Balance and strength training (E2) with a weight of 0.5956, 0.3771, and 0.3351are ranked first, second, and third among the criteria, respectively. Conclusions The outcomes of the research help healthcare systems to allocate preventive care resources more efficiently.

1317 A QUALITY IMPROVEMENT PROJECT AIMING TO ENHANCE THE RECOGNITION OF INPATIENT WEIGHT LOSS ON AN ELDERLY WARD

Abstract Background Weight loss in the older adult is often multifactorial and can be associated with increased morbidity and mortality. Our quality improvement project focused on nutritional care of patients 75 years or older. This hospital has a standardised Nutrition and Hydration Policy based on NICE guidelines to prevent malnutrition in hospital inpatients including weighing patients every 72 hours, daily screening and food/hydration charts. Our project aimed to increase adherence, with a focus on increasing the percentage of patients being regularly weighed over a 6-month period to 90%. Methods Our stakeholder analysis highlighted the multidisciplinary nature of our project, particularly involving the healthcare assistants. The percentage of patients weighed within 72 hours was recorded weekly. The first PDSA cycle introduced the project and gained buy-in from the MDT, highlighting required weights in MDT meetings/board rounds. The second cycle included an education session for doctors. The third cycle involved a poster in each bay aiming to act as a prompt and promote patient and family involvement. Results Our run chart shows that following our first two PDSA cycles eight consecutive results were higher than the baseline (40% of patients weighed). Results ranged from 70-90%. Following the third intervention compliance returned to baseline but coincided with significant disruption to the ward structure and team. Our successful intervention of nutritional teaching was then repeated as a fourth PDSA cycle and the mean returned to 80%. Conclusions Nutritional care requires multidisciplinary involvement. The educational session had the most impact and in future could be delivered to additional MDT members. Disappointingly the poster did not stimulate patient or family participation. We would like to create an ethos on elderly wards where nutrition routinely features in ward-based comprehensive geriatric assessments. Future plans hope to further engage patients and families as visiting restrictions eased.

1257 IMPROVING HYDRATION IN ELDERLY PATIENTS ON OUTLIER WARDS AT NEWHAM UNIVERSITY HOSPITAL (NUH)

Abstract Introduction Dehydration is a major contributing factor to morbidity and mortality in elderly patients, as they are at greater risk and more vulnerable to the consequences of inadequate fluid intake. Care of the Elderly (COE) wards are set up to meet the specific care needs of elderly patients, however, these care needs are not consistently met on medical outlier wards at NUH. This project aimed to improve hydration-related patient care on outlier wards using a sustainable intervention by increasing average daily fluid intake (ADFI) by 50% and patients with drinks within an arm’s reach by 50%. Methods Cycle 1: Hydration parameters (ADFI, glasses within reach, drinks offered, glasses filled) were audited for patients on two COE wards (n=25) and four outlier wards (n=19). Cycle 2: Reminder to offer patients a drink added to outlier patients’ ward round entries and nurses verbally informed over 1 week (n=14). Cycle 3: ‘Think Drink’ poster placed at outlier patients’ bedsides as a visual reminder and nurses verbally informed over 1 week (n=15). Results Cycle 1: ADFI was 774mls greater on COE than outlier wards, 299% more glasses within reach, 62% more drinks offered, 78% more glasses filled. Cycle 2: 52% increase in ADFI (258mls), 104% more drinks within reach, 11% more drinks offered; 15% less glasses filled. Cycle 3: further 8% increase in ADFI (62mls), 87% more glasses within reach, 4% more drinks offered, and 124% more glasses filled. Overall: 65% increase in ADFI, 280% more glasses within reach, 15% more drinks offered, and 90% more filled glasses. Conclusions An important gap in care was identified between COE and outlier wards, leaving elderly outlier patients vulnerable to dehydration. ‘Think Drink’ poster acted as a successful visual reminder for staff and visitors demonstrated by an increase in all hydration parameters, improving hydration-related patient care.

1151 IMPROVING THE MEASUREMENT OF POSTURAL BLOOD PRESSURE WITH AD-HOC MOBILE TEACHING SESSIONS FOR NURSES AND HEALTHCARE ASSISTANTS

Abstract Introduction Falls are a major cause of morbidity and mortality in patients over 65. Unrecognised postural hypotension is a significant and treatable contributor. Training nurses and health-care assistants (HCAs) in correct measurement technique can be challenging, as these groups are rarely able to fully attend single sessions due to urgent clinical commitments, night duties and staff-shortages. We aimed to improve the frequency and quality of lying-standing blood pressure (LSBP) measurement in a Geriatric inpatient cohort. Methods Three PDSA cycles were performed over a 10-month period on a single Care of the Elderly ward, including an initial audit in March 2021. The outcome measures were: 1. the percentage of non-bedbound patients having LSBP correctly measured (5-min recumbent, 1 and 3-min standing readings), assessed by chart review and 2. the understanding and confidence of measurers in correct technique, as assessed by a questionnaire. The intervention was developed into three separate days of ad-hoc mobile teaching sessions to allow reinforcement of knowledge. Trainers moved from bay-to-bay delivering a 5-minute pre-prepared presentation/demonstration on the indications and correct technique of LSBP measurement. This was repeated throughout each day until all measurers had participated. Results On initial assessment, only 21% (6/28) of non-bedbound patients had LSBP correctly measured. This improved to 44% (8/18) by July and 62% (8/13) by December 2021. When sampled, measurers had sustained improvements from July (n=8) to December (n=7), in terms of self-rated confidence (mean 4.4/5 vs 4.9/5), correct technique (25% vs 100%), interpretation of results (25% vs 43%) and knowledge of contraindications to measurement (88% vs 100%). Conclusions We describe a strategy using ad-hoc mobile teaching sessions to train nurses and HCAs to measure LSBP in a Geriatric inpatient cohort, which resulted in sustained improvements. We believe this technique is readily applicable to other units and areas of practice.

1169 QUALITY IMPROVEMENT PROGRAMME ON NON-MEDICINAL MANAGEMENT OF POSTURAL HYPOTENSION AMONG MDT MEMBERS IN THE MEDICAL WARDS (COE)

Abstract Introduction Postural Hypotension is a very common presentation in the elderly population. Appropriate knowledge to record postural hypotension and non-medicinal management for this is very important among MDT members working in the care of the elderly wards. Method We set out a questionnaire to assess the knowledge among MDT (multidisciplinary) members. An educational programme was initiated to improve the knowledge among MDT members. A complete audit cycle was done and the knowledge was reassessed with the same questionnaire based on the principles of the PDSA (Plan, Do, Studt and Act) cycle. Results It showed that the correct way of checking for postural blood pressure improved from 52.4% to 92% in recording the blood pressure. Correct identification of postural blood pressure improved from 33.3% to 88%. Self-rating of confidence to identify correctly postural blood pressure improved from 47.6% to 64% among the MDT Members. It was difficult to compare the answers about non-medicinal methods and exercises to help postural hypotension as there was heterogeneity in answers. It was also not possible to compare the impact of individual interventions on the alleviation of postural blood pressure. Conclusion Good improvement in the recording and non-medicinal management of Postural hypotension was observed in both the wards among the MDT Members. It is very important to have good knowledge and understanding in the management of this common condition as it helps in the identification and better management.

50 SERVICE EVALUATION COMPARING ACUTE CARE AT HOME FOR OLDER SEOPLE SERVICE AND CONVENTIONAL ACUTE HOSPITAL CARE OF THE ELDERLY WARD

Abstract Background Globally, there has been an increased demand for healthcare services caused by population growth and a rise in chronic conditions and an ageing population. Acute Care at Home services offer acute, hospital-level care in a person's own home. Five services have been commissioned across Northern Ireland since 2014 with limited research investigating their feasibility and effectiveness. This study evaluated the impact of a consultant-led Acute Care at Home service in comparison with conventional hospital admission to a care of elderly ward. Methods Quantitative design, using service evaluation methodology. A 1-year retrospective chart review was undertaken exploring admission demographics and post-discharge clinical outcomes of patients admitted to a Northern Ireland, Care of the Elderly ward (n = 191) and a consultant-led Acute Care at Home Service (n = 314) between April 2018–March 2019. Data were analysed using descriptive and inferential data analysis methods including frequencies, independent t tests and chi-square analysis. Outcome measurements included length of stay, 30-day, 3-and 6-month readmission and mortality rates, functional ability and residence on discharge. STROBE checklist was used in reporting this study. Results Acute Care at Home services are associated with higher readmission and mortality rates at 30 days, 3 and 6 months. Patients admitted to the Acute Care at Home services experience a reduced length of stay and decreased escalation in domiciliary care packages and are less likely to require subacute rehabilitation on discharge. There is no difference in gender, age and early warnings score between the two cohorts. Conclusion The Acute Care at Home service is a viable alternative to hospital for older patients. It prevents functional decline and the need for domiciliary care or nursing home placement. Acute Care at Home service has higher mortality and readmissions rates due to treating a higher proportion of dependent, frail older adults.

Anti-cholinergic drug burden in patients with dementia increases after hospital admission: a multicentre cross-sectional study

BackgroundAnticholinergic medications are drugs that block cholinergic transmission, either as their primary therapeutic action or as a secondary effect. Patients with dementia may be particularly sensitive to the central effects of anticholinergic drugs. Anticholinergics also antagonise the effects of the main dementia treatment, cholinesterase inhibitors. Our study aimed to investigate anticholinergic prescribing for dementia patients in UK acute hospitals before and after admission.MethodsWe included 352 patients with dementia from 17 UK hospital sites in 2019. They were all inpatients on surgical, medical or Care of the Elderly wards. Information about each patient’s medications were collected using a standardised form, and the anticholinergic drug burden of each patient was calculated with an evidence-based online calculator. Wilcoxon’s rank test was used to look at the correlation between two subgroups upon admission and discharge.ResultsOn admission to hospital, 37.8% of patients had an anticholinergic burden score ≥ 1 and 5.68% ≥3. On discharge, 43.2% of patients with an anticholinergic burden score ≥ 1 and 9.1% ≥3. The increase in scores was statistically significant (p = 0.001). Psychotropics were the most common group of anticholinergic medications prescribed at discharge. Of those patients taking cholinesterase inhibitors, 44.9% were also prescribed anticholinergic medications.ConclusionsOur cross-sectional, multicentre study found that people with dementia are commonly prescribed anticholinergic medications, even if concurrently taking cholinesterase inhibitors, and are significantly more likely to be discharged from hospital with a higher anticholinergic burden than on admission.

131 Sleeping It Off - Are Hospital Wards Too Noisy to Allow Patient Recovery?

Abstract Aim Increased overnight noise levels are known to stimulate the release of multiple stress hormones and negatively impact upon objective and subjective sleep quality. Increasing levels of noise impairs physical and psychological recovery, and has been shown to slow wound healing, increase complication rates, and lengthen hospital admissions. Noise levels are therefore an important component of post-operative care and recovery. The purpose of this study is to document the actual noise levels experienced by patients overnight and analyse the sources of noise. Method Firstly, five-minute recordings were made during four separate hours throughout the night on two wards - one paediatric and one adult. Secondly, researchers described and categorised the sources of noise. Results The World Health Organisation (WHO) has recommended that average overnight noise levels in hospitals should not exceed 35 dB. The average recorded on the paediatric and elderly ward was 42.27 dB and 43.91 dB, with peak noise levels of 93.65 dB and 97.01 dB respectively. In every five-minute recording, there was at least one sound louder than 67 dB. Researchers identified multiple avoidable and non-avoidable causes. Conclusions The average noise level was significantly greater than the WHO recommendations. Every five-minute recording contained peak sounds of significance. Such noise levels have been linked to poor sleep, increased stress hormone release, delayed wound healing, and an increased post-operative recovery time. Many feasible solutions to address the avoidable causes of these sounds are identified. Addressing this issue is important for both medical and surgical units and is likely to improve patient outcomes.

1052 CLINICAL MEDICATION REVIEWS AND OPTIMISATION FOR INPATIENTS IDENTIFIED AS FRAIL ON THE ELDERLY CARE WARDS AT EAST LANCASHIRE HEALTH TRUST

Abstract Introduction Inpatient medication review occurs daily on our elderly wards and NICE (clinical guideline NG5) advocates using a Stopp/Start tool. Polypharmacy and tablet burden are common issues in frail patients and medications should be under regular review. Evidence of these reviews can be laborious to identify in written notes, particularly for frail patients with complex discharges. We aimed to determine whether clinical medication reviews are documented clearly at ELHT and to improve this. Method Patients with a Rockwood frailty score of ≥6 were identified and inpatient notes and charts audited for written detail of medication reviews and drug changes, then compared to the trust Stopp/Start toolkit. Cycle 1 was prior to intervention. We then delivered clinical education on medication optimisation and prompted use of ‘medications review’ proforma on existing trust documents. Cycle 2 occurred after this, then following changeover of junior doctors educational sessions were repeated and cycle 3 data collected. Results 82% of all patients audited had altered medications with a mean hospital stay of 8 days. On cycle 1 65% of patients with altered medications had documentation to explain medication changes, on cycle 2 this improved to 88% and 72% on cycle 3. 92% of patients had a documented medication review (even if this involved no drug changes) at cycle 1 which improved to 100% on cycle 2 and remained at 92% on cycle 3. Both before and after intervention medications were appropriately rationalised or introduced. Conclusion We were already conducting regular reviews and optimising medications for frail patients. Prior to intervention there were inconsistencies on how this was documented. Through education and proforma for documentation this greatly improved, in turn improving communication and continuation of care on discharge. We are introducing electronic records to the trust and aim to include medication reviews into this system.

976 QUALITY OF DISCHARGE SUMMARIES FROM A CARE OF THE ELDERLY WARD—A QUALITY IMPROVEMENT PROJECT

Abstract Introduction Deficits in transfer of information between secondary and primary care are common but can have significant impact on patient care and can often be dangerous as well. It’s hard to quantify the quality of a discharge summary but certain parameters can be reasonably used as its surrogate. Method After review of literature from multiple sources, we identified 6 key indicators to assess quality of discharge summaries for patients discharged from a Care of the Elderly ward. In round 1, we collected data from 129 discharge summaries created over a period of 12 months. After analysis of data, a plan including education of doctors, posters display in wards and emphasis on compliance in ward rounds and MDTs was implemented. Round 2 of the QIP was performed 4 months later and data was collected from 50 discharge summaries. Results Significant improvement in compliance seen in all areas assessed which include; 1. Main diagnosis during admission—improved from 93% to 100% 2. Mobility at discharge—Improved from 31% to 82% 3. Resuscitation status—improved from 6% to 86% 4. Medication changes during admission and their rationale—20% to 62% 5. Discharge destination—66% to 96% 6. Social care requirements e.g. package of care etc.—59% to 82%. Conclusion Plan implemented after round 1 has led to a significant improvement in quality of discharge summaries which consequently results better communication between secondary and primary care. This improvement especially surrounding medication changes translates into better continuity of care and patient safety.

1067 IMPROVING STOOL CHART DOCUMENTATION ON A CARE OF THE ELDERLY WARD

Abstract Introduction Constipation is a common and often overlooked problem with potentially serious consequences, including patient discomfort, urinary retention, delirium and bowel obstruction. These consequences can lead to prolonged hospital stay, increased healthcare costs and increased morbidity and mortality. Accurate stool chart documentation is an essential part of basic care that helps prevent this. The aim of the project was to increase daily stool chart documentation, including stool type, to 70% on a care of the elderly ward in a medium-sized district general hospital. Method We created a proforma to review each patients’ stool chart from the previous 24 hours. Daily data was collected by measuring the number of correctly completed stool charts on the ward. Initial baseline data showed an average daily completion rate of 24%. We tested 3 separate interventions over a 6 week period using Plan-Do-Study-Act (PDSA) methodology: Intervention 1- Increase staff awareness about stool charts via email, posters and at handovers Intervention 2- Complete stool charts every time routine observations are performed Intervention 3- Complete online stool charts. Results All interventions led to an improvement in the average daily stool chart completion rate. Intervention 1 caused the most significant improvement with the average daily stool chart completion rate increasing to 77%. Intervention 2 was the least successful change, with an average daily stool chart completion rate of 39%. Intervention 3 had an average daily stool chart completion rate of 64%. Conclusion Simple interventions like staff education and prompts to help culture and behaviour change led to a significant improvement in stool chart documentation rates. Paper documentation (intervention 1) fared better than online documentation (intervention 3) most likely due to the former requiring fewer processes to complete. Intense monitoring and documentation (intervention 2) was unsuccessful and was perceived to be burdensome.

1063 THE CHALLENGES OF PROVIDING ADEQUATE AND APPROPRIATE NUTRITION AND HYDRATION CARE TO HOSPITAL MEDICAL INPATIENTS

Abstract Introduction Nutrition and hydration are essential components of hospital inpatient care. Inadequate provision has been shown to be linked to poorer outcome. We performed a cross-sectional study of nutritional care in a London teaching hospital. Method Data collection was undertaken in October 2021 across two medical wards. Data for demographics; morbidity factors including: Charlson Comorbidity index (CCI), length of stay (LoS), cognitive score (AMTS); nutrition parameters and their recorded accuracy including: weight, ‘MUST’ score, fluid balance, food chart, and evidence of dietetic referral and review were examined. Results 52 patients were assessed [male 24/52 (46.15%), median age 80.5 (IQR 61.75–85.25, range 30–98)]. The median CCI score was 5, corresponding to 21.36% estimated 10-year mortality, with median LoS of 8 days (IQR 3–15.25). AMTS was recorded in 12/52 (23.08%). Variable recording of nutrition parameters was observed (weight: 57.69%, ‘MUST’ score 23.1%, fluid balance 63.5%, food chart 15.4%). Only 54.6% of the recorded fluid balance charts were clinically accurate. Where oral nutritional supplement (ONS) was prescribed, 57.1% (8/14) of patients had not received a dietetic review. Upon comparison the care of the elderly ward demonstrated a significantly higher accuracy of fluid balance chart (60% vs 46%, p < 0.001). Discussion Supporting patients to meet nutrition and hydration goals is a core component of clinical care. Our results demonstrate that nutrition and hydration care is poorly documented across several parameters, and by inference, poorly delivered irrespective of age, co-morbidity or cognitive impairment. Less than 1/3 of patients had a formal nutrition screen suggesting that identification of patients at risk of malnutrition should be the priority for future work. An electronic health record allows easy access to data that can be used for improvement. As an achievable first step, an improvement in awareness of nutritional scores, such as MUST, will be important in identification of malnutrition.