Quality Improvement Posters 1014 – 1020

Quality Improvement Posters 1014 – 1020

1014 Building the palliative care pyramid

Adam Bhanji


Background: Challenges have been identified in approaching, discussing and communicating the transition into palliative care. Holistic support is an integrated part of the palliative care pyramid; clinicians should be able to treat patients as a whole, from medical and psychosocial point of view.

Aim: To identify the need for an integrated approach to palliative care to improve care in the last days of life.

Method: A critique of PubMed and an internet review of the literature regarding the medical and holistic approach to palliative care and communication with patients.

Results: ‘There are no precise ways of telling accurately when a patient is in the last days of life.’ Clinical indicators, based on the gold standards framework can be used to identify the palliative needs of patients. Prognostic indicators can only assist clinicians in recognising dying patients; healthcare professionals need to get to know their patients and gain an understanding of their individual disease trajectory. There are no specific communication tools for discussing patient’s prognosis, however the most important aspect to patients is to be realistic and have an individualised approach.

Conclusion: Guidance on illness trajectories and prognostic indicators can only act as a rough guide in supporting patients, families and healthcare professionals at the end of life. The pyramid model of palliative care gives a visual tool to help clinician’s approach both the medical and holistic aspects of palliative care and recognise the opportunities for flexibility in moving around the pyramid to offer individualised patient care.

1015 Gout in primary care: can we improve patient outcomes?

Linda Sloan


Aims: To evaluate the demographics and attendance patterns of patients with gout in an inner city practice To reduce gout flares and GP attendances.

Content: In the UK, gout is a common inflammatory arthropathy mainly managed in primary care. Despite being a red flag indicator for cardiovascular disease, there are few standardised treatment protocols and suboptimal management is common. A computer-based retrospective search between October 2014 – March 2015, identified 115 patients with gout. Demographic information was collated and the frequency of flares was noted. The patients were sent a diet, lifestyle and advice sheet. A re-audit was completed one year later to assess any improvements.

Impact: 22% of patients experienced a flare during the initial study period. Independent risk factors for gout flares included high urate levels (p=0.0001), younger age (p=0.009), fewer co-morbidities (p=0.039) and lower cardiovascular disease risk (CVDr) scores (p=0.038). Independent risk factors for gout-related GP consultations were fewer co-morbidities (p=0.0301), younger age (p=0.013) and higher urate levels (p=0.00027). In the final six months of the intervention period, October 2015 – March 2016, there was an 80% reduction in gout flares (p=0.0003) and GP attendances reduced from 80 to 10 (p=0.0001). Uric acid levels decreased from 0.37 to 0.30 mmol/L(p=0.14).

Outcome: Simple interventions supported by a multi-disciplinary team can effectively improve disease control and patient outcomes.

Discussion:This project highlighted gout as a condition that disproportionately affects healthy, young, working age people. By improving disease control, morbidity can be significantly alleviated, thereby reducing GP consultations and potentially reducing absence from work.

1016 Preventing osteoporotic fragility fractures in primary care – how can we improve?

Thanuya Francis


Background: Osteoporosis is a common condition, particularly among over 65s. If left untreated, it can result in fragility fractures which are associated with morbidity and mortality. Due to the asymptomatic nature of the condition, before fractures occur, osteoporosis is largely underdiagnosed and undertreated. NICE guideline recommends identifying individuals at risk of fragility fractures according to specific risk factors. Currently, QoF only covers secondary prevention of osteoporosis. With an ageing population, greater emphasis should also be placed on preventing osteoporosis in the first instance.

Aims: To review the current guideline on osteoporotic fracture prevention and discuss its application to primary care.

Method: EMIS search of a London practice with 4500 patients identified individuals at risk of fragility fractures, of whom PMHx, FRAX/QFracture scores and/or DEXA scan results were reviewed.

Results: 362 patients (8%) were identified as at risk of osteoporotic fragility fractures, significantly lower than the local prevalence rate. 27% of these patients who were aged ≥40 years had their fragility fracture risk accessed, among whom 3% had their absolute risk estimated and 1% further had FRAX/QFracture scores determined to predict their 10-year absolute risk. Furthermore, only two patients aged <40 years were identified to have ≥1 major risk factor of osteoporosis; neither of whom had their BMD measured.

Discussion: Systems should be implemented in primary care that improves detection of at risk patients; for instance, QoF indicators for primary prevention of osteoporosis. This will allow for prompt management, reducing complications such as fragility fractures and thus reducing morbidity and mortality.

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1017 CKD: teaching patients and staff

Rachel Yi Ling Kuo


Aims: Chronic kidney disease (CKD) is a common disease, with prevalence estimated to be greater than 10%, sharply rising in the over 60 age group. It is associated with significant morbidity, mortality and reduced quality of life. It is important to identify patients who are at risk of progressing through CKD stages to intervene prior to end-stage renal failure. Included in this, patients must be educated regarding CKD and given lifestyle advice.

We aimed to improve CKD recognition and provide patient and staff education to improve CKD management for our GP practice. Content:Inclusion: over 18 and under 75 years old; eGFR 29 recorded in the past 5 years confirmed on 2 blood tests taken at least 3 months apart. Exclusion: patients with a more recent eGFR >60We identified 27 patients with CKD Stage 3, and a further 27 patients who needed a further blood test to confirm CKD status.

We compared our management to NICE guidance. We created a patient information leaflet, a covering letter and a feedback form to send out to patients. If any investigations were outstanding we requested patients to book in. We developed a presentation, and a written resource to improve staff awareness of CKD.

Impact/Outcomes: We were able to identify and successfully educate all 27 patients, of whom all 27 found the information “quite useful” or “very useful”. Staff targeted for education included GP trainees, practice nurses and medical students. We also improved compliance to NICE guidelines to 100% in our practice.

Discussion: Through our two-pronged approach, we were able to improve knowledge about CKD in both patients and professionals, and thus improve our patient management.

1018 PSA: Prostate Specific Antigen, how are we doing?

Harvinder Mann


Aim: To assess whether or not counselling is being conducted with patients before a PSA test is conducted.

Content: Prostate Specific Antigen (PSA) is a glycoprotein enzyme, whose serum levels are used clinically as a biomarker. Despite having its limitations, it is the most reliable current test for prostate cancer. A key limitation is that it may give a false positive or false negative result. For this reason, the Prostate Cancer Management Programme in 2002 set out key patient counselling guidelines to be used by physicians before this test is requested. With many of the PSA tests conducted in general practice, it is of great use to conduct an audit to assess the extent to which this counselling is conducted, and whether any improvements could be made to encourage this guideline to be followed.

Outcomes: This audit, conducted in a rural practice set out to measure whether this counselling is being given to a patient prior to the PSA test request. The test was requested for 75 patients over a 18 month period. It was found that counselling was only recorded in 27 patients, amounting to 36% of patients. Of the 8 PSA tests that returned with abnormal results, only one patient was counselled prior to that test being conducted. This leaves 7 patients who were left vulnerable to the limitations of the test.

Discussion:This gives indication that changes are needed to improve to amount of patients that are being counselled before the PSA test, and also that a record of this counselling should be kept. It would be of value to re-audit this area 18 months after changes have been made.

1019 Forget me not in Somerset

Emma Ramsay


Somerset has a population of which 23% are aged 65 and over. Nationally the percentage of patients with dementia who have a diagnosis is 67.2% whereas the Somerset percentage is 61.5%. The aim of my project was to identify on a practice level where we could improve and reach the Prime Minister’s target of 66% of patients diagnosed.I under took an audit of 15 practices searching for patients who had presented with memory loss at some point to their GP. I looked at the memory clinic letters to check whether a diagnosis had been made but not coded, and I considered whether there was sufficient evidence from the notes for the GP to make a clinical diagnosis. I also looked for patients on acetylcholinesterase inhibitors with no dementia diagnosis.

I have found 87 patients so far and I am intending to visit more practices. Dementia is a key health priority and is estimated to cost more than cancer, heart disease or stroke. The Prime Minister’s challenge details how dementia care should look in 2020, and early diagnosis of dementia is vital to enable patients to access the support and follow up they need.The recommendations of my project are that all practices should conduct yearly searches to identify patients with dementia who may have been missed, and those with memory loss which may have progressed to dementia. I have also written a report for the CCG about the benefits of GP led diagnosis and how this could be introduced in the Somerset area.

1020 Admissions Avoidance Care planning: Improving Future Service Design and Delivery

Jennifer Rea


Background Patients with multiple co-morbidities & complex care needs have a higher risk of emergency hospital admissions (EHAs). These are often distressing, preventable and place huge financial burden on the NHS. In 2014, NHS England launched a GP initiative offering personalised care-plans for vulnerable patients, trying to optimise care & reduce EHAs. AimsEvaluation of the AACP process from GPs & patients perspective with specific focus on personal goal-setting MethodsA quantitative study based in a London GP surgery over 6 months (2015). Two surveys were designed for patients and doctors respectively. 215 patients and 11 GPs were invited to complete a questionnaire (post or on-line).

Outcomes 33% response rate for the patient survey. 54% felt the AACP had improved their care. The most commonly used terms to describe the plan were personal, informative and relevant. 79% of respondents read their care plan or showed it to someone. 76% of patients found personal goal setting beneficial & 76% felt more able to make change afterwards. 82% response rate for the GP survey. 72% of GPs felt the AACP had made little difference to patient care. Doctors most commonly used negative terms to describe care-planning eg. not empowering and a poor use of time. Few GPs were confident that patients would utilise their plan. Half reported finding goal setting challenging. 78% were unclear on the efficacy of the AACP process before it began.

Discussion Findings suggests AACPs are broadly welcomed by patients but GP confidence in the process was lacking. Personalised goal setting was appreciated by patients & did motivate behaviour change for some. The project uncovered a learning need for doctor training in health coaching.