Healthcare Improvement Scotland Research Articles

Scottish Intercollegiate Guidelines Network Guidance on Dementia: The Investigation of Suspected Dementia (SIGN 168) with Focus on Biomarkers-Executive Summary.

This is an executive summary of the recent guidance produced by the Scottish Intercollegiate Guidelines Network (SIGN) dementia guideline group with regards to the investigation of suspected dementia. This is a sub-section of the broader SIGN 168 guideline released in November 2023. The guideline group included clinicians with expertise in Old Age Psychiatry, Neurology, Radiology, and Nuclear Medicine supported by colleagues from the SIGN and Healthcare Improvement Scotland teams. There was representation from carers and support organizations with experience of dementia, to ensure the recommendations were appropriate from the perspective of the people being assessed for possible dementia and their carers. As the 2018 National Institute for Health and Clinical Excellence (NICE) dementia review included a review of the evidenced investigation of dementia, the SIGN guideline development group decided to focus on a review on the up-to-date evidence regarding the role of imaging and fluid biomarkers in the diagnosis of dementia. To give context to the consideration of more advanced diagnostic biomarker investigations, the guideline and this summary include the NICE guidance on the use of standard investigations as well as more specialist investigations. The evidence review supports consideration of the use of structural imaging, nuclear medicine imaging, and established Alzheimer's cerebrospinal fluid biomarkers (amyloid and tau) in the diagnosis of dementia. Although routine use of amyloid positron emission tomography imaging was not recommended, its potential use, under specialist direction, in patients with atypical or young-onset presentations of suspected Alzheimer's dementia was included as a clinical good practice point.

Frailty Assessment in Vascular OUtpatients Review (FAVOUR) protocol: single-centre prospective cohort study comparing feasibility and prognostic value of commonly used frailty assessment tools

IntroductionFrailty has consistently demonstrated associations with poorer healthcare outcomes. Vascular guidelines have recognised the importance of frailty assessment. However, an abundance of frailty tools and a lack of prospective studies...

How a National Organization Works in Partnership With People Who Have Lived Experience in Mental Health Improvement Programs: Protocol for an Exploratory Case Study.

This is a research proposal for a case study to explore how a national organization works in partnership with people with lived experience in national mental health improvement programs. Quality improvement is considered a key solution to addressing challenges within health care, and in Scotland, there are significant efforts to use quality improvement as a means of improving health and social care delivery. In 2016, Healthcare Improvement Scotland (HIS) established the improvement hub, whose purpose is to lead national improvement programs that use a range of approaches to support teams and services. Working in partnership with people with lived experience is recognized as a key component of such improvement work. There is, however, little understanding of how this is manifested in practice in national organizations. To address gaps in evidence and strengthen a consistent approach, a greater understanding is required to improve partnership working. The aim of this study is to better understand how a national organization works in partnership with people who have lived experience with improvement programs in mental health services, exploring people's experiences of partnership working in a national organization. An exploratory case study approach will be used to address the research questions in relation to the Personality Disorder (PD) Improvement Programme: (1) How is partnership working described in the PD Improvement Programme? (2) How is partnership working manifested in practice in the PD Improvement Programme? and (3) What factors influence partnership working in the PD Improvement Programme? An exploratory case study approach will be used in relation to the PD Improvement Programme, led by HIS. This research will explore how partnership working with people with lived experience is described and manifested in practice, outlining factors influencing partnership working. Data will be gathered from various qualitative sources, and analysis will deepen an understanding of partnership working. This study is part of a clinical doctorate program at the University of Stirling and is unfunded. Data collection was completed in October 2023; analysis is expected to be completed and results will be published in January 2025. This study will produce new knowledge on ways of working with people with lived experience and will have practical implications for all improvement-focused interventions. Although the main focus of the study is on national improvement programs, it is anticipated that this study will contribute to the understanding of how all national public service organizations work in partnership with people with lived experience of mental health care. DERR1-10.2196/51779.

1288 IMPROVING STAFF AWARENESS OF FRAILTY IN THE EMERGENCY DEPARTMENT: A MULTI-DISCIPLINARY QUALITY IMPROVEMENT PROJECT

Abstract Introduction Comprehensive Geriatric Assessment (CGA) improves outcomes for frail older adults in acute hospitals. Patients aged 75 and over admitted into the Emergency Department (ED) at the QEUH will automatically generate a “frailty icon” on their electronic record. The number of frail people accessing emergency care is increasing. This Healthcare Improvement Scotland (HIS) frailty tool prompts staff to assess for frailty and refer to the local Frailty Pathway if appropriate. We designed a multidisciplinary quality improvement project (QIP) to increase completion of the frailty icon and the number of referrals to the frailty service from the ED. Methods Both medical and nursing staff in the ED were targeted for intervention. Weekly data was collected on the percentage of patients aged 75 and above who were discharged from the ED with a “frailty icon” completed over a 3-month period. Our main intervention was to hold a frailty awareness month. This involved multiple sub-interventions such as; announcements at handovers, e-mails, word-of-mouth, and posters. Results The weekly percentage of completed “frailty icons” increased from 28% 2 weeks pre-intervention (n = 283) to 48% in 1 month (n = 258). A peak of 57% (n = 293) completed icons was achieved immediately after our intervention. These increases were then sustained for a further 6 weeks with a weekly average baseline of 45.2% completion (average n = 281). Increased “frailty icon” completion in the ED led to a 100% increase in referrals to the frailty pathway. Conclusion Increasing awareness of frailty amongst ED staff results in increased front door assessment for frailty, and subsequent referral to the frailty team. This allows for more patients to receive a CGA. Multidisciplinary QIPs utilise the skills of diverse staff groups to best achieve sustainable change.

AGREEing on Clinical Practice Guidelines for Autism Spectrum Disorders in Children: A Systematic Review and Quality Assessment.

Background: Autism spectrum disorder (ASD) is a multifaceted neurodevelopmental disorder requiring multimodal intervention and an army of multidisciplinary teams for a proper rehabilitation plan. Accordingly, multiple practice guidelines have been published for different disciplines. However, systematic evidence to detect and intervene must be updated regularly. Our main objective is to compare and summarize the recommendations made in the clinical practice guidelines (CPGs) for ASD in children released from November 2015 to March 2022. Methods: CPGs were subjected to a systematic review. We developed the inclusion and exclusion criteria and health-related questions, then searched and screened for CPGs utilizing bibliographic and CPG databases. Each of the CPGs used in the study were critically evaluated using the Appraisal of Guidelines for REsearch and Evaluation II (AGREE II) instrument. In a realistic comparison table, we summarized the recommendations. Results: Four eligible CPGs were appraised: Australian Autism CRC (ACRC); Ministry of Health New Zealand (NZ); National Institute for Health and Care Excellence (NICE); and Scottish Intercollegiate Guidelines Network, Healthcare Improvement Scotland (SIGN-HIS). The overall assessments of all four CPGs scored greater than 80%; these findings were consistent with the high scores in the six domains of AGREE II, including: (1) scope and purpose, (2) stakeholder involvement, (3) rigor of development, (4) clarity of presentation, (5) applicability, and (6) editorial independence domains. Domain (3) scored 84%, 93%, 86%, and 85%; domain (5) 92%, 89%, 54%, and 85%; and domain (6) 92%, 96%, 88%, and 92% for ACRC, NICE, NZ, and SIGN-HIS, respectively. Overall, there were no serious conflicts between the clinical recommendations of the four CPGs, but some were more comprehensive and elaborative than others. Conclusions: All four assessed evidence-based CPGs demonstrated high methodological quality and relevance for use in practice.

PP414 Improving The Accessibility Of Scottish Medicines Consortium Advice

IntroductionThe Scottish Medicines Consortium (SMC) provides advice on which new medicines should be accepted for routine use by the NHS in Scotland. To help increase the accessibility of the advice, SMC produces public information summaries, which have been published on the SMC website since 2018. We conducted an evaluation to investigate if the public summaries are achieving their purpose and subsequently help inform improvements from a user perspective. The objectives were to determine how the public summaries are being used; what users like and what could be improved; and if they have achieved a greater understanding of decisions.MethodsThe first stage of the evaluation involved surveying patient groups (organizations that represent the interests of patients, families and carers) to investigate how they use the public summaries. We then conducted workshops with patient groups and Public Partners (members of the public that volunteer with Healthcare Improvement Scotland) to gather perspectives on the content, language and layout of a selection of public summaries.ResultsThe survey responses (n = 14) illustrate that the public summaries are being used in a variety of ways. The majority (n = 10) of patient groups reported using the public summaries to help explain SMC decisions to the people they support.The workshops highlighted that participants found the public summaries clear and helpful. In general, patient groups felt the level of detail and language used in the public summaries improved their understanding of SMC decisions compared to other sources of information, such as the press release or Detailed Advice Document.There were a number of suggested improvements, including changing the layout (so the SMC decision appears first) and providing definitions for some technical terms. Where actionable, these recommendations have been implemented.ConclusionsWorking in partnership with patient groups and Public Partners has enabled SMC to further strengthen public summaries, and patient engagement more broadly. Improvements have ensured that SMC's decisions are communicated clearly, helping to increase accessibility.

PP293 Tiered Rapid Response Products In The Evidence Directorate Of Healthcare Improvement Scotland

IntroductionThe Evidence Directorate produced eighteen rapid responses during the early stages of the COVID-19 pandemic. To address this need while retaining methodological integrity a three-tiered system for rapid responses was developed.MethodsAll rapid responses answer specific research questions rather than broad health system issues. The appropriate level varies depending on the time and resource available, and the requester's need: •Level 1 – Reference List (turnaround 4–8hrs, delivered by an information scientist): a quick search for best available evidence, and results presented as a reference list.•Level 2 – Summary of evidence (turnaround 1–2 days, delivered by an information scientist): a quick search and brief summary of the best available evidence.•Level 3 – Synthesis of evidence (turnaround 3–7 days, delivered by a Health Services Researcher or Health Economist): a quick search and then a narrative summary and synthesis of the best available evidence, with a brief appraisal of validity, reliability and generalizability.ResultsSince the launch of the three-tiered model in September 2020 there have been five rapid responses. Two were Level 2 products and three were Level 3 products.ConclusionsThe Evidence Directorate of Healthcare Improvement Scotland now has an agile rapid response product which can be applied to a variety of settings and needs. This was borne out of a need for a rapid turnaround and evidence synthesis during the COVID-19 pandemic.

Staff survey on using the new clinical risk assessment framework for teams (CRAFT) tool

AimsRisk assessment and management are crucial elements of clinical practice in mental health. Healthcare Improvement Scotland identified risk management as a key area for change, with risk tools identified as one necessary component. In NHS Greater Glasgow and Clyde (GG&C) the CRAFT tool replaced the Glasgow Risk Screen (GRS) in October 2019. The CRAFT tool is a 2 page document that comprises a broad risk screen, details of historical risk events and prompts for family and carer involvement. The aim of this study was to assess staff attitudes to the CRAFT, 12 months after it had been rolled out. Looking at whether the CRAFT tool is used to inform decision making about risk in clinical settings and if patients were involved in the risk management process.MethodAn electronic staff survey was distributed to all clinical staff within NHS GG&C Mental Health Services. Clinical staff includes the following professional groups: Medical, Nursing, Psychology, Occupational Therapists and Allied Health Professionals. Contact details were accessed via the relevant managers and surveys were sent via secure global address lists. Questions were focused around the following areas: time taken to complete/update/frequency of use/contact and ease of use, role in decision making, patient and carer involvement/knowledge, view on the impact of the CRAFT.ResultThere were 209 responses. This represents a response rate of approximately 10%. 89% of respondents had completed a CRAFT tool at some point but only 38% had received training. 15% reported that the CRAFT did not aid decision making about risk in clinical settings, whereas 37% said it did and 42% said it did sometimes. 46% report patients are consulted most of the time (34%) or always (12%). The qualitative impression was that the CRAFT was an improvement on its predecessor. However common themes from responders highlighted a lack of clinical relevance or impact decision making, lack of training in filling it out and cumbersome integration with the electronic case notes.ConclusionStaff perceptions of the CRAFT tool were generally negative with many feeling it was a box ticking exercise that had minimal real world impact on patient risk and its management. However many felt it was an improvement over the previous risk tool and the majority used it at some point to aid clinical decision making.

94 The Comprehensive Frailty Assessment At Forth Valley Royal Hospital (FVRH) Digitalised: For COVID-19 and Beyond!

IntroductionComprehensive Geriatric Assessment (CGA) improves outcomes for frail patients; at FVRH this is delivered by the Frailty Intervention Team (FIT) comprising of senior nurses, allied health professionals (AHPs) and doctors. Faced with COVID-19, we took the opportunity to digitalise CGA documentation to preserve these benefits for patients whilst facing greater acuity, staffing and time pressures. An electronic solution was adopted to reduce paper-usage in COVID-receiving areas. Prior to COVID-19, CGA was recorded within case-notes, presenting challenges when patients were readmitted out-of-hours as these were stored off-site and not accessible out-of-hours.MethodTrakcare is the patient-management system in many Scottish hospitals. The Electronic Patient Record (EPR) was used to record pro-forma against admissions which were accessible and updatable for any patient 24–7-365. Patients meeting the Healthcare Improvement Scotland (HIS) Frailty criteria were considered “frailty-positive”, with an e-alert added- reappearing on any re-admission. Providing no HIS-exclusion criteria, an electronic-CGA (e-CGA) was recorded or updated. The pro-forma designed contained information not immediately available to clerking practitioners. This evolved following discussion amongst the FIT to include information such as escalation-status, medication-arrangements and baseline cognition.ResultsOver 13 weeks, 116 EPRs were reviewed. During weeks 1–3 (n = 8, 12, 7 respectively), e-CGA completion averaged 31%. Following FIT collaboration, this rose to 82% (n = 9) by week 12. Qualitative feedback from the MDT indicated that FIT, downstream wards and night-staff felt that having access to previous escalation-plans made immediate-management easier to determine, and discussions with families more productive for patients.ConclusionsDevelopment of the FVRH e-CGA is ongoing, with an electronic frailty-screening tool being implemented to improve frailty-identification on admission to ensure correct streaming of patients to the FIT. We have demonstrated a cost-neutral method for improving access to CGA for patients using existing IT systems whilst protecting staff time, preserving patient care during the COVID-19 pandemic.

An evaluation of the formalised AcciMap approach for accident analysis in healthcare

This paper presents a field workshop organised by the Healthcare Improvement Scotland (HIS) focusing on the evaluation of the formalised AcciMap approach by patient safety practitioners of the National Health Service (NHS). Participants who were experienced in incident analysis relating to patient safety and risk management across different NHS boards but had no prior knowledge using the AcciMap approach were recruited for a case study analysis (Wrong Patient) (Chassin and Becher in Ann Intern Med 136:826–833, 2002). They were subsequently divided into three teams after introduction and training, where each team performed an independent case analysis. AcciMap outcomes produced indicated both similar and varying contributing factors identified by each team. This was also reflected in their formulation of safety recommendations. Their findings were then compared with each other (reliability) and with external review (validity). Based on results obtained from the survey instrument distributed after the exercise and focus discussions, the AcciMap approach was generally perceived as intuitive and a potentially relevant toolkit for incident investigations. However, questions were raised particularly regarding the usability (ease of use) in conducting analyses compared RCA techniques.

User testing a patient information resource about potential complications of vaginally inserted synthetic mesh

BackgroundVaginal mesh implants are medical devices used in a number of operations to treat stress urinary incontinence and pelvic organ prolapse. Although many of these operations have delivered good outcomes, some women have experienced serious complications that have profoundly affected their quality of life. To ensure that evolving patient information is up-to-date, accurate and appropriate, the Transvaginal Mesh Oversight Group ‘user-tested’ a newly developed Scottish patient resource, the first to focus exclusively on the issue of complications. The aim of this research was to gather feedback on usability, content, language and presentation to inform the development of the resource from a user perspective.MethodsThe experience of using the patient resource was captured through semi-structured interviews that followed a ‘think-aloud’ protocol. The interviewer observed each participant as they went through the resource, asking questions and making field notes. Participants’ comments were then categorised using a validated model of user experience and subsequently analysed thematically.ResultsThirteen people participated in the user testing interviews, including women with lived experience of mesh implants (n = 7), a convenience sample of staff working for Healthcare Improvement Scotland (n = 5) and a patient’s carer (n = 1). The majority of participants considered the resource as clear and helpful. Respondents reported that some presentational aspects promoted usability and understandability, including the use of a font that is easy to read, bullet lists, coloured headings and simple language. Barriers included the reliance on some technical language and an explicit anatomical diagram. Participants endorsed the valuable role of health professionals as co-mediators of patient information.ConclusionsThe findings illustrate the value of undertaking in-depth user-testing for patient information resources before their dissemination. The study highlighted how the direct guidance or navigation of a patient information resource by a health professional could increase its salience and accuracy of interpretation by patients, their families and carers. These insights may also be useful to other developers in improving patient information.

Assessment of inpatient diabetes knowledge among healthcare professionals in a district general hospital

AimsDiabetes mellitus is a commonly encountered diagnosis in hospitalised patients that is associated with prolonged admissions and mortality. One in six hospital beds in the UK are occupied by diabetes patients. Therefore, healthcare providers need to have a sound knowledge in managing in-patients with diabetes. Thus the aim of this clinical survey was to assess the diabetes-related knowledge of healthcare professionals in a district general hospital. MethodsA 24-item questionnaire, based on the ‘Think Check Act (TCA)’ diabetes modules implemented by the Healthcare Improvement Scotland was issued to the medical and nursing staff. Simple statistics were used for data collation and analysis. Results30 questionnaires were completed by 10 doctors at varying stages of training, 17 nurses, 1 physician associate and 2 healthcare assistants. The mean percentage score of the participants were 57.4%. 22 (73.3%) correctly defined hypoglycaemia and 27 (90%) knew the location of hypo box and 7 (23.3%) were aware of TCA. Responses to other management related to diabetes emergencies were average. The responses between doctors and nurses were insignificant except for hypo box location (p = 0.0413). ConclusionKnowledge about managing inpatient diabetes problems amongst healthcare professional at a district general hospital appears mediocre. Significant gaps have been identified which would be targeted for future educational events.

A systematic review of the use, quality and effects of pelvic examination in primary care for the detection of gynaecological cancer

Aim: This three part systematic review gathered all the current evidence on the use, quality and effects of pelvic examination (abdominal palpation, bimanual vaginal examination ± visualisation of the cervix) in primary care in diagnosing gynaecological cancer.Research questions• Do primary care practitioners perform pelvic examination during the assessment of symptoms, which are potentially indicative of gynaecological cancer? (RQ1)• What is the quality of pelvic examination performed in primary care, in terms of technical competence and interpretation of findings? (RQ2)• Is pelvic examination associated with the referral of patients with gynaecological cancer, and if so, in what way? (RQ3)Methods: PRISMA guidelines were followed. MEDLINE, EMBASE and Cochrane databases were searched using a combination of four terms, their MeSH terms and synonyms: pelvic examination; primary care; competency and gynaecological cancer. Inclusion and exclusion criteria were defined. Citation lists of all identified papers were searched. Two authors (PW and PM or CMB or CB) independently screened titles, abstracts and the full texts of publications. Data extraction was performed by PW and duplicated in all papers by a second reviewer (PM, CMB or CB). Paper quality was assessed using CASP methodology.Results: Nine hundred fifty four references were identified: 21 met the inclusion criteria: 5 RQ1; 6 RQ2; 10 RQ3. Examination rates prior to referral were generally low: one paper identified pre-referral PE in 52% of the patients; remaining papers demonstrated examination in less than half of the patients with suspicious symptoms. No papers explored GPs’ competence at performing PE directly; but one paper identified 39% of ‘clinically suspicious’ cervices referred for colposcopy as having no abnormality. Pre-referral PE was associated with reduced diagnostic delay and early stage diagnosis.Conclusions: Pre-referral pelvic examination in symptomatic women appears to be under-performed, despite urgent suspected cancer referral guideline recommendation to do so (Healthcare Improvement Scotland 2014; National Institute for Health and Care Excellence 2015). While no evidence was found to confirm GPs’ competence for performing PE, there was an association with shorter diagnostic delay and better outcomes in those women where it was performed.

Developing a framework to evaluate knowledge into action interventions

BackgroundThere are many challenges in delivering and evaluating knowledge for healthcare, but the lack of clear routes from knowledge to practice is a root cause of failures in safety within healthcare. Various types and sources of knowledge are relevant at different levels within the healthcare system. These need to be delivered in a timely way that is useful and actionable for those providing services or developing policies. How knowledge is taken up and used through networks and relationships, and the difficulties in attributing change to knowledge-based interventions, present challenges to understanding how knowledge into action (K2A) work influences healthcare outcomes. This makes it difficult to demonstrate the importance of K2A work, and harness support for its development and resourcing. This paper presents the results from a project commissioned by NHS Education for Scotland (NES) and Healthcare Improvement Scotland (HIS) to create an evaluation framework to help understand the NHS Scotland Knowledge into Action model.MethodsThe team took a developmental approach to creating an evaluation framework that would be useful and practical. This included a literature review to ensure the evaluation was evidence-based; adaptation of contribution analysis for K2A project; action research with K2A project leads to refine the work and develop suitable measures.ResultsPrinciples for evaluation and an evaluation framework based on contribution analysis were developed and implemented on a trial project. An outcomes chain was developed for the K2A programme and specific projects. This was used to design, collect and collate evidence of the K2A intervention. Data collected routinely by the intervention was supplemented with specific feedback measures from K2A project users.ConclusionsThe evaluation approach allowed for scrutiny of both processes and outcomes and was adaptable to projects on different scales. This framework has proved useful as a planning, reflecting and evaluation tool for K2A, and could be more widely used to evidence the ways in which knowledge to action work helps improve healthcare outcomes.

Regulation of independent clinics in Scotland: what impact has it had so far?

One of the most recent major regulatory changes in aesthetics—that aesthetic clinics in Scotland would have to register with the country's health-care regulator—was announced almost 2 years ago. As phase one of Healthcare Improvement Scotland's regulation has come to an end, with details of phase two to emerge in due course, Andrew Malyon explores how well the initiative has worked so far

An Audit of Staphylococcus aureus Bacteraemia Treatment in a UK District General Hospital

Objective: Recent guidelines from Healthcare Improvement Scotland recommend that uncomplicated Staphylococcus aureus bacteraemia (SAB) be treated with effective antibiotics for at least 14 days. This audit aimed to see whether Medway Hospital, UK, was following these guidelines, and whether a simple intervention could improve compliance and therefore treatment. Method: All patients with SAB between April 2013 and September 2014 were identified and their clinical notes, laboratory findings and drug charts were reviewed. Starting in January 2014 all SAB were reported on the online pathology results system with the following advice; ‘Staphylococcus aureus bacteraemia warrants a minimum of 14 days treatment. Treatment may be longer in cases of deep seated infection.’ Outcome measures included 14 days antimicrobial treatment readmission rate with SAB, 3 month mortality post treatment and whether echocardiography was performed. Results: The demographics of all patients (35 pre and 39 post intervention) were comparable between groups (average age 63 vs 56, 54.3% vs 69.2% male) although the sources of bacteraemia differed slightly. More patients had indwelling lines in 2013 and there were a higher proportion of IV drug users in 2014; all other risk factors were similar between groups. More patients received appropriate antibiotics post intervention (74% vs 49%). Three month mortality with community acquired SAB increased but mortality with hospital acquired SAB decreased post intervention. Echocardiography uptake improved, and readmission rates with SAB decreased. Conclusion: The introduction of guidance with blood culture results has demonstrated better compliance with a 14 day minimum treatment length for SAB. Although sample size limits obtaining a statistically significant difference in readmission and mortality rates, this intervention still has the potential to improve treatment of SAB in aiding clinicians to follow guidelines. J Microbiol Infect Dis 2017; 7(4):188-193

The administration of blood components: a British Society for Haematology Guideline.

The administration of blood components: a British Society for Haematology Guideline.

'Keep the patient at the centre of everything you do'.

What is your job? I am nurse consultant for older people in acute care at NHS Fife in Scotland, where I lead on improving care, transitions and experience and service transformation. I am also national clinical lead for older people at Healthcare Improvement Scotland (HIS).

What impact will Healthcare Improvement Scotland's regulations have on standards?

As of 1 April 2017, independent clinics providing non-surgical cosmetic procedures in Scotland are required by law to be registered with the country's national health-care improvement organisation. Phase one of regulation is now complete, with phase two in the pipeline. Jackie Partridge, a member of Healthcare Improvement Scotland's programme board, explores how this will affect patient safety and quality of care

Protecting patients: pressure ulcer prevention.

John Tingle, Reader in Health Law, Nottingham Trent University, continues his discussion of Healthcare Improvement Scotland patient safety publications and its standards for management of pressure ulcers.