Reducing harm from polypharmacy in older people (Summer 2017)

Polypharmacy is common among older people; it can increase the risk of adverse drug reactions and interactions, as well as reduce compliance and adherence.

Positive (but inconsistent) effects of deprescribing interventions have been observed.

Patient and practitioner decisions about stopping medications are influenced by social influences, expected consequences, and factors such as consultation length.

Practitioners said their own knowledge and skills, plus beliefs about the capabilities of patients could influence their decisions.

Patients said their emotions, treatment goals, and willingness to experiment could also influence their decisions.

A multifaceted person-centred coordinated care approach, as advocated in NICE clinical guidelines and by the ‘House of Care’ model, should underpin efforts to reduce harm from polypharmacy in older people.

Effectiveness Matters - Polypharmacy (PDF , 922kb)

Acute Kidney Injury: the 5Rs approach (Winter 2015)

The 5Rs approach to managing AKI includes: Risk, Recognition, Response, Renal support and Rehabilitation. 

Patients at Risk of AKI should avoid episodes of dehydration and nephrotoxins. 

Recognition of AKI is dependent upon good clinical judgement, careful monitoring of urine output and measurement of serum creatinine.

Rapid Response to AKI includes screening for sepsis, avoidance of toxins, optimisation of blood pressure and preventing harm (STOP AKI).

Patients with severe AKI should be referred and receive Renal support.

Patients with or at risk of AKI, and their carers, should receive appropriate Rehabilitation including details about risk factors for AKI, preventative measures, treatment options and possible outcomes.

Effectiveness Matters - Acute Kidney Injury (PDF , 204kb)

Triage and minimising crowding in emergency departments (Spring 2015)

Crowding happens in all emergency departments and is associated with increased mortality, reduced quality of care and staff burnout.

Triage scales are useful in identifying the least urgent cases.

Senior doctor triage may help to reduce length of stay in the emergency department, but further research is needed to support any transition to possible models of doctor triage.

Primary care staff in emergency departments may be useful but further research is needed to determine effective models of working.

“Fast-tracking” less urgent patients can reduce the time to initial contact with a doctor and emergency department length of stay.

 Effectiveness Matters - Triage (PDF , 203kb)

Recognising and managing frailty in primary care (Spring 2015 - updated Spring 2017)

Frailty is a distinct health state where a minor event can trigger major changes in health from which the patient may fail to return to their previous level of health.

Simple tests that have been recommended by NICE for frailty in primary care are gait speed, self-reported health status and the PRISMA 7 questionnaire.

Exercise programmes, particularly high intensity interventions, may improve gait, balance and strength and have positive effects on fitness.

Medication review forms part of the holistic medical review of people with frailty.

Supported self-management can improve health outcomes. However, the value of case management has still to be proven.

Discussion about end-of-life care is important to most older people, but is often neglected.

Effectiveness Matters - Frailty (PDF , 660kb) 

Housing improvement and home safety (Autumn 2014)

The homes we live in impact on health, wellbeing and health inequalities.

Treating illnesses directly related to living in cold, damp and dangerous homes costs the NHS £2.5 billion per year.

Ensuring affordable warmth through insulation and more efficient heating can improve health and wellbeing.

Home safety assessment and modification can reduce falls and risk of falling in older people.

Education, promotion of exercise and wearing of appropriate footwear, environmental modifications and training of healthcare workers can reduce the rate of fall-related injuries (including fractures) in older people.

Homes can be made safer through education delivered by health or social care professionals, school teachers, lay workers, and voluntary organisations.

 Effectiveness Matters - Housing (PDF , 372kb)

Preventing pressure ulcers (Autumn 2014)

Pressure ulcers affect around 5% of patients: but the majority of these may be avoidable.

Pressure ulcers can become painful, infected and malodorous, reduce health related quality of life and increase length of hospital stay.

Multicomponent interventions are recommended, incorporating: pressure-relieving surfaces, skin inspections, repositioning of patients, incontinence/moisture management, and nutrition/hydration support.

Key to implementation are: simplification and standardisation of pressure ulcer specific interventions, multidisciplinary teams and leadership, accountability and celebrating success, designated skin champions and ongoing education.

There is evidence of cost savings from pressure-ulcer prevention programmes.

Effectiveness Matters - Preventing pressure ulcers (PDF , 239kb)

Preventing falls in the community (Autumn 2014)

Falls can have a devastating effect on independence, confidence, and quality of life.

Multicomponent assessment of falls risk for individuals is essential to identify the appropriate targeted interventions.

Group and home-based exercise programmes, and home safety interventions reduce rate of falls and risk of falling.

To improve implementation, beliefs and behaviours at individual, organisational and societal levels need to be addressed.

Consultation with older people is essential to ascertain what changes they are prepared to make to reduce their fall risk.

Active training and support of health professionals is needed to implement falls prevention programmes in practice.

Effectiveness Matters - Preventing falls in the community (PDF , 193kb)

Impact of early warning systems on patient outcomes (Autumn 2014)

Many in-hospital deaths are predictable and preventable and are often associated with poor clinical monitoring on the ward.   Early warning scoring systems are widely used in hospitals to track patient deterioration and to trigger escalations in clinical monitoring and response.

National adoption of the NEWS system is advocated.   The evidence base for early warning systems is very limited but does suggest potential reductions in cardiac arrests and unplanned ICU admissions.

Substantial resources are being invested in electronic early warning systems across the NHS. Given finite budgets, monitoring of costs, resource use and impact on patient outcomes is crucial to any deployment.

Continuous training and support for ward level staff (including bank nurses) will be integral to system implementation and to longer term maintenance.

Effectiveness Matters - Early warning systems (PDF , 259kb)

Preventing falls in hospitals (Summer 2014)

Falls in hospital impact on quality of life and health, and cost the NHS more than £2.3 billion per year.

An individualised falls risk assessment is essential to identify targeted prevention interventions.

The use of single or multicomponent interventions is effective in reducing the risk of falls in hospitals.

Effective components in prevention programmes include: engagement of front-line staff in the design of interventions, use of falls data, attitude change away from the inevitability of falls and training to promote adherence.

Board and ward level leadership and support are consistently associated with implementation success.

Ongoing monitoring of adherence is important for the maintenance of long-term changes.

Effectiveness Matters - Preventing falls in hospitals (PDF , 187kb)

Dementia carers (Spring 2014)

Carers are the mainstay of dementia care in the UK and the Alzheimer’s Society estimate that at least 670,000 people are acting as a primary carer.

As dementia is on the increase, carers will be essential in helping health and social services meet the demand for care. Carers are known to experience high rates of depression and anxiety. Their need for practical and emotional support to relieve the stress of caring is equally high.

Psychosocial therapy can improve carers’ health and well-being; combining two or more psychosocial interventions is likely to be more effective than a single intervention.

Developing carers’ coping skills can improve their psychological health and well-being.

Carers indicate they need staged access to clear and understandable information about dementia generally and on the availability of advice and support services.

Effectiveness Matters - Dementia Carers (PDF , 710kb)

Patient Safety (Summer 2013)

The Francis Report detailed some of the worst failings in care and unnecessary harm to have occurred in the NHS.

The government announced a series of measures they hope will deliver a culture of zero-harm and patient centred care in the NHS.

There is a large evidence base that the NHS can draw upon to inform their efforts to improve patient safety.

The ten key practices highlighted in this bulletin range from establishing a culture for patient safety through to interventions aimed at reducing specific events.

Clear and visible leadership, engagement of front-line clinical staff and interventions that target prevailing attitudes are key.

Delivering harm free care should involve routine monitoring of meaningful outcomes. Areas of concern can be identified and targeted so that improvements can be sustained.

Effectiveness Matters- Patient Safety (PDF , 376kb)