February 2024 – app.mlcsu

February 27, 2024

In-depth analysis and insight: A cancer pathway review within Staffordshire and Stoke on Trent Integrated Care Board

As referenced in the national NHS priorities and operational planning guidance for 2023/24, the significance of early cancer diagnosis is an NHS priority. One of the biggest actions the NHS can take to improve cancer survival is to diagnose cancer earlier. Patients diagnosed early, at stages 1 and 2, have the best chance of curative treatment and long-term survival. The NHS Long Term Plan set the ambition that, by 2028, the proportion of cancers diagnosed at stages 1 and 2 will rise to three-quarters of cancer patients. Achieving this will mean that, from 2028, 55,000 more people each year will survive their cancer for at least five years after diagnosis.

NHS Midlands and Lancashire Commissioning Support Unit (MLCSU) are pleased to be supporting this ambition, working in collaboration with Staffordshire and Stoke-on-Trent Integrated Care Board (ICB) to deliver a deep dive cancer pathway analysis, funded by the West Midlands Cancer Alliance. The areas of focus of this in-depth review are late-stage cancer diagnosis and a review of primary care cancer referrals. The programme of work aims to identify and investigate variations in the cancer pathway, and the impact these have on patient outcomes.

The insight gained from understanding variation in cancer pathways, will inform recommendations to improve the patient experience by optimising referral to diagnosis timescales, and improving early diagnosis, where possible and appropriate.

The programme of work is being led by the MLCSU Business Intelligence team, in collaboration with the MLCSU Nursing and Urgent Care team, together with the involvement of relevant teams within the Digital, Data and Technology Directorate. Our joint approach is key to the delivery of the project, which encompasses a clinical audit as part of the cancer pathway analysis. The analysis and engagement to date have proved instrumental in informing discussions with the ICB and wider stakeholders, in determining which cancer sites form the focus of the clinical audits.

Working in partnership with the ICB, primary care and the cancer services teams in the designated acute hospital providers within the Staffordshire and Stoke on Trent geography, means we can incorporate a wide source of data and information, and obtain the required input from clinical specialists as part of a case study approach. This methodology enables a rich study to develop, with early findings providing the evidence needed to inform recommendations for improvement and transformation of cancer pathways across the integrated care system.

Further information

If you would like to find out more about this programme of work, and how we may potentially support your organisation in this area, please contact:

Lead Consultant Analyst Ruth Green at ruth.green24@nhs.net

Head of BI Consultancy Mark Oliver at mark.oliver1@nhs.net

Chief Analytics Officer Neil Morgan at neil.morgan1@nhs.net

February 21, 2024February 22, 2024

Reducing the use of Lorazepam at a dementia nursing care home

Our Medicine Optimisation Care Home team successfully reduced the reliance on regular Lorazepam prescriptions in elderly residents of a dementia nursing care home, improving medication safety and appropriateness through comprehensive structured medication reviews and a multidisciplinary approach.

Background

A GP practice in Preston observed a concerning trend at a local dementia nursing care home. There was a notable increase in the number of Lorazepam prescriptions, alongside requests to shift from ‘when required’ to ‘regular’ dosing for its residents. Lorazepam, typically prescribed for short-term management of anxiety or insomnia with anxiety, is known for side effects such as drowsiness, loss of coordination, dizziness, and a heightened risk of falls, especially in the elderly. The primary goal was to ensure that the prescription of Lorazepam was clinically appropriate for each resident. This involved a collaborative effort with the care home’s carers, the GP, and the specialist mental health team, forming a multidisciplinary approach to optimise patient outcomes.

Action

NHS Midlands and Lancashire CSU’s (MLCSU) Medicine Optimisation Care Home (MOCH) team initiated a series of structured medication reviews (SMRs) for residents on Lorazepam, assessing the appropriateness of its prescription. The care home was guided to enhance care plans, detailing each resident’s typical and atypical behaviours. These plans were to include explicit guidelines on alternative techniques to be attempted before the administration of Lorazepam. During weekly ward rounds, the MOCH pharmacist, accompanied by an advanced nurse practitioner from the GP practice, reviewed positive behaviour plans and evaluated the judicious use of Lorazepam. Recommendations based on these evaluations were discussed and implemented as needed.

Impact

Over three months, the MOCH team conducted 12 structured medication reviews for residents prescribed Lorazepam, with a notable majority (83%) of these patients aged 75 or older. The initiative led to a total of 54 interventions categorised by their impact on patient safety and care quality:

– Low impact interventions (7 instances): These interventions included examples such as modifying paracetamol prescriptions to variable repeats and reducing the quantity of sodium feredetate from 500ml to 300ml for a 28-day supply.

– Medium impact interventions (38 instances): Actions taken included dose adjustments for antidepressants due to adverse ‘hang-over’ side effects, mental health referrals, and discontinuation of no longer needed medications like Lactulose, presenting a moderate risk to patient safety.

– High impact interventions (7 instances): These interventions had the potential to significantly impact patient safety, including the cessation of Lorazepam in a resident with Alzheimer’s disease, indicating a direct approach to minimising harm.

The team’s efforts resulted in 27 instances of cost savings, amounting to £7,137 annually. Additionally, 25 medicines were discontinued, contributing to a more streamlined and safer medication regimen for the residents.

Specific outcomes related to lorazepam included:

– Lorazepam was discontinued for 6 residents.

– For 2 residents, Lorazepam was adjusted from ‘regular’ to ‘when required’ doses.

– 3 residents experienced dose reductions.

– 1 resident’s Lorazepam treatment was deemed still appropriate after review.

For residents where lorazepam was discontinued, tailored positive behaviour plans were developed. These plans emphasised distraction techniques such as discussing family and organising activities such as singing and drawing to manage behaviours without medication.

The work of the MOCH team enhanced ongoing communication between the GP practice and the nursing care home, resulting in a collaborative environment for continuous improvement in patient care. Following the latest Care Quality Commission inspection, the care home received positive feedback for their approach to medication safety, specifically regarding the reduced use of ‘as and when required’ medicines. This multi-faceted approach underscores the significant strides taken to ensure the well-being and safety of residents through meticulous medication management and the promotion of non-pharmacological interventions.

Feedback

‘Working alongside Tanveela on medication reviews was a pleasure, undertaking 12 structured medication reviews for patients prescribed Lorazepam. The outcome was beneficial for the patients and a great learning curve for me, working alongside with someone with the experience to guide me to make switches for the benefit of the patients. The review highlighted the need to be aware of medication effects and the side effects for patients, the impact of not over-sedating, prevention of falls, and the prevention of admissions. Discussing positive behaviour plans also impacts greatly on the patient’s daily living and being able to manage escalations of mood. The interventions proved very successful. Anne-Marie Potter | Advanced Nurse Practitioner

February 21, 2024

Enhancing stroke risk management by developing a comprehensive reporting dashboard

The implementation of the cardiovascular disease prevention dashboard markedly enhanced stroke prevention strategies, offering healthcare providers critical data on key risk factors and driving substantial improvements in the diagnosis and management of atrial fibrillation, hypertension, and high cholesterol.

Background
In 2019, the Lancashire and South Cumbria Integrated Care Board (ICB) embarked on a significant health initiative with the release of its five-year stroke prevention strategy. This strategy highlighted a critical need: the effective monitoring of stroke prevention efforts, particularly focusing on three key risk factors – atrial fibrillation, hypertension, and raised cholesterol.

The primary goal was to develop a tool to enable health commissioners and providers to track and manage these risk factors effectively. This initiative led to the creation of the cardiovascular disease (CVD) prevention dashboard.

Action

Our Business Intelligence team played a pivotal role in realising this vision. They developed a comprehensive, visual dashboard, hosted on Aristotle Xi, a robust platform known for its data-handling capabilities.

The dashboard offers a unique, multi-dimensional view, enabling analysis from various healthcare perspectives, including integrated care systems, integrated care boards, primary care networks, and GP practices.

Regular updates are managed and refreshed quarterly by our Business Intelligence team and the report ensures up-to-date data is always at hand.

Target-driven indicators have been developed in collaboration with our data quality teams, and the dashboard provides crucial indicators. It also sets aspirational targets, focusing on priority indicators.

Impact

The dashboard has been instrumental in providing concrete evidence linking stroke risk to the management of atrial fibrillation, high blood pressure, and high cholesterol levels. This tool empowers users to identify and address gaps in the detection and management of these risk factors.

The pandemic posed significant obstacles, notably in the routine management of hypertension. The dashboard has been pivotal in responding to these challenges, guiding practices in managing hypertension effectively and aligning with NHS England’s monitoring blood pressure at home programme.

Moreover, the dashboard aids practices in adopting proactive measures in managing patients, especially those with a cardiovascular disease risk greater than 20%. It serves as a guide in achieving the national stroke prevention targets.

Feedback

“We now have clear evidence that in addition to many lifestyle factors, risk of stroke is associated with the diagnosis and management of atrial fibrillation, uncontrolled high blood pressure and the identification and treatment of high cholesterol. This dashboard allows users to identify the size of detection and management gaps for each of these risk factors.

COVID has led to many patients not receiving their annual hypertension checks and NHSE has responded to the risk of this, increasing the incidence of heart attacks and strokes by launching their blood pressure at home programme. Practices are encouraged to use this dashboard to inform them of their position in relation to achieving the national stroke prevention targets for patients on their hypertension registers and adopt a proactive approach to their management where appropriate.

Finally, the dashboard will inform practices on their position in relation to starting prescribing for patients with a cardiovascular disease risk of greater than 20%.” Jean Hayhurst | Cardiovascular Specialist Nurse