Improving the Assessment of Patients >75 years admitted under General Surgery: Focusing on Treatment Escalation and Frailty Scoring

Jocelyn Cheuk, Alice Raban

Introduction

Treatment Escalation Plan encompasses decisions surrounding Do Not Attempt Cardio -pulmonary Resuscitation (DNACPR) and patients' ceiling of care. Previous research highlighted that survival to discharge following CPR is 15-20% and this figure is much lower amongst elderly and frail patients. Appropriate DNACPR decisions following discussion with patients and their family members can facilitate a natural and more dignified death. The Rockwood Clinical Frailty Scale (CFS) is a holistic and global clinical measure of a person’s level of function and vulnerability two weeks prior to their deterioration, which can help facilitate TEP discussions. This quality improvement project was set up following recognition that completion of TEPs and CFS documentation is lower in some specialties such as General Surgery.

Aim

>70% patients >75 years old with TEP & Rockwood Clinical Frailty Score (CFS) documented

Initial Audit

• 71 admissions of patients >75 years old between Oct and Nov 2020

• 44% with TEP form and 37% with CFS.

Cycle 1 Results

• 66 admissions between Dec 2020 and Jan 2021

• 62% with TEP form and 51% with CFS

Qualitative survey:

• barriers to completion identified

• 58%: senior review is the most appropriate time for TEP. 92% supported inclusion of TEP forms into clerking proforma

Intervention 1

• Placed copies of TEP forms into the surgical assessment proformas and highlighted the Frailty Score box already in the proforma.

• Qualitative survey regarding surgical team’s thoughts

Cycle 2 Results

• 52 admissions between May 2021 and June 2021.

• 39% with TEP form and 29% with CFS

Summary

Results from Cycle 1 were promising and demonstrated that visual aids have an impact in prompting early completion of TEP forms and CFS scores. Results from Cycle 2 demonstrated no impact and several limitations were identified:

• Sample size was smaller than previous cycles

• Timing of intervention coincided with significant Covid-related changes to the structure of the surgical team.

There is no doubt that there are significant benefits in early completion of TEP forms and Rockwood CFS scores

Intervention 2

• Informal teaching from surgical registrars to clerking teams

The comparative success and failures of methods trialed helped identify learning points and guide future interventions in this ongoing quality improvement project.

Future Directions

• Rollout of ReSPECT forms within the trust

• Formal teaching with input from geriatric team

• Online training via Clinical Frailty Network

• Encourage documentation of TEP discussions in discharge summaries

Quality Improvement Project: Reducing The Delay Between Hip Hemiarthroplasty Surgery and Post-Op Check X-Ray

Authors: Dr. Kaustabh Sen (FY2 Clinical Fellow), Mr Andrew Gardner (Specialty Registrar, Trauma and Orthopaedics), Miss Lydia Jenner (Specialty Registrar, Trauma and Orthopaedics), Miss Jemma Rooker(Consultant Trauma and Orthopaedics)

Introduction

Approximately 28,000 hip hemiarthroplasties are performed for fracture each year in the NHS. The Getting it Right First Time (GIRFT) initiative recommends a post-operative x-ray (XR) to ensure satisfactory position of components and to assess for an iatrogenic fracture.

Methods/PDSA cycles

Consecutive patients were identified through the National Hip Fracture Database. Electronic patient records and radiograph systems were scrutinised for date of XR request, date of postoperative XR and date of discharge. A total of three PDSA cycles over an 18-month period were performed.

Not idle between cycles

Between each cycle, staff education sessions, posters and policy change was implemented to ensure the operating surgeon requested the XR.

Lessons learned:

Requests on admission or at time of surgery was associated with a quicker time to post-operative XR. In the third PDSA cycle, when the mean number of days (NOD) between operation (OP) and XR was 5 days, the mean length of stay (LOS) was 12 days. When this was >5 days, the mean LOS was 16 days. Streamlining post-operative XRs reassured hip fracture patients the operation was successful and was associated with a shorter hospital stay. Continued proactive XR requesting is vital in this cohort of patients to avoid risks of prolonged bed rest and hospital stay.

Aims

To assess time between surgery and post-operative XR

To identify any reasons for delay To Streamline the protocol

R= Average number of days (NOD) between operation (OP) and XR request

X= Average NOD between OP and XR