bluuebunny/crossref_metadata_2025 huggingface dataset:
Demethylation strategies for spiro-OMeTAD to enhance the thermo-opto-electronic properties as potential hole transport materials in perovskite solar cells
Authors: Syed Mahadzir Puteri Intan Zulaikha , Mottakin M , Abdah Muhammad Amirul Aizat Mohd , Fahsyar Puteri Nor Aznie , Jumbri Khairulazhar , Mahyuddin Muhammad Haris , Sepeai Suhaila , Mat Teridi Mohd Asri , Ludin Norasikin Ahmad , Su’ait Mohd Sukor , Nazeeruddin Mohammad Khaja
Published: August 2024

Spiro-OMeTAD is a widely used hole-transporting material (HTM) that plays a crucial role in achieving highly efficient perovskite solar cells (PSCs). In this work, a series of demethylated functionalized spiro-OMeTAD-based derivatives with different numbers of hydroxyl substituted groups (named as SOH2, SOH4, and SOH6) were synthesized, and their thermal, optical, electrical, and electrochemical properties have been investigated as potential HTMs for PSCs. It has been found that the molecule with six hydroxyl substituted groups on the spiro-OMeTAD-based structure SOH6 exhibited the highest glass transition temperature (T
g) and melting point (T
m) as compared to SOH2 and SOH4 molecules. The UV–vis absorption spectra portrayed a distinct pattern with the increase in hydroxyl substituted groups as it was slightly blue-shifted for the SOH6 molecule compared to red-shifted for SOH2 and SOH4 molecules. Carrier mobility shows a notable improvement with the hydroxyl substitution. The density functional theory (DFT) has provided useful insight into identifying the chemical stability of spiro-OMeTAD derivatives. In the device simulation, hydroxyl-substituted spiro SOH2 was found to outperform its pristine counterpart, achieving a peak PCE of 17.61% with a V
oc of 0.98 V, a J
sc of 22.69 mA cm−2, and an FF of 80.67% within the device structure FTO/TiO2/MAPbI3/HTMs/Au. This investigation provided insight into the development of novel spiro-OMeTAD-based derivatives with enhanced optoelectronic properties and showed promising potential for addressing the limitations of traditional HTMs in PSCs.
A systematic review of studies investigating the link between greenspaces and human health reveals a paucity of interest in the topic in Africa
Authors: Phogole Bopaki , Yessoufou Kowiyou
Published: August 2024

Whilst the human population is declining in some parts of the world, the African population is growing tremendously despite recurrent epidemics and global pandemics. Since African population density is higher where plant diversity is high and 80% of the African population relies on herbal medicine, the resilience of the African population in the context of disease outbreaks may be linked to a strong tie of Africans with nature. However, is the potential effect of such a tie well established in the scientific discourse? To investigate this question, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We found that very few studies tested the relationships between greenspaces and human health conditions on the continent. Out of the 54 African countries, studies that investigate the link between greenspaces and health are from only six countries and the earliest study was published only in 2013, indicating the recency of research on this subject in Africa. These few studies, not only report mixed findings but are also heterogeneous in terms of their design (longitudinal versus cross-sectional), the choice of predictors and health outcomes as well as how these variables are measured. This review showed that there is a paucity of studies on the greenspace and human health nexus on the continent, making it difficult i) to establish or generalise the relationships between greenspaces and human health conditions in Africa, and ii) to investigate the mechanisms driving the effects of nature on human wellbeing in Africa. To fuel interests and guide future research on the continent, the rate of knowledge generation needs to be rapidly increased, and this requires first the identification of current barriers. Second, we need to update curricula at African universities to include statistical modelling which can fuel interest into more hypothesis-driven (rather than just descriptive) studies.
Field monitoring and numerical simulation for force characteristics of pipe jacking in deep buried moderately weathered slate
Authors: Zheng Shuang , Luo Zhimin , Wang Chuanqi , Zhang Yongjie
Published: August 2024

Understanding the force characteristics of pipe jacking in rock formations is crucial for ensuring the stability of the structure and construction safety during construction. Yet, very little is explored about its characteristics in rock formations of pipe jacking. This paper presents a case study of constructing a deeply buried moderately weathered slate sewage pipeline using pipe jacking method in Changsha, China. To this end, we propose a novel method to combine field monitoring and numerical simulation representation in an efficacious way. Field monitoring was conducted to investigate the spatial distribution characteristics of jacking force, axial stress, and hoop stress in moderately weathered slate. Numerical simulation methods were employed to discuss the influences of several factors on pipe stress: the pipe-rock contact area, contact relationships at pipe joint interfaces, the height of the jacking force position, and the depth of pipe burial. The results show that hand shield is influenced by the excavation technology, and the distribution of jacking force exhibits a stepped or oscillating upward pattern in moderately weathered slate. The maximum axial stress occurs at the mid-span position of the arched roof of pipe at 30 MPa. Hoop stresses are dominated by compressive stresses with the maximum at-8 MPa. As the pipe burial depth increases, so does the axial stress on the pipe. Lower positioning of the jacking force heightens this stress effect. A larger pipe-rock contact area correlates with reduced axial stress levels. The weakening of the contact interface between pipe joints minimally affects axial stress, as stress primarily transmits through non-weakened areas. To ensure the reliability of the data, automatic monitoring and measuring instruments calibrated for on-site monitoring are used. The results of this study can provide beneficial guidance for the design and construction of pipe jacking.
Parametric modeling of resin-bonded sand mold systems using machine learning-based approaches
Authors: Samal Priyaranjan , Khadanga Kanhu Charan , Surekha B , Vundavilli Pandu R
Published: August 2024

This study presents the experimental investigations on modeling of the compression strength and permeability of the resin-bonded sand mold system through Machine Learning approaches. The process of constructing the Fuzzy Logic system was automated by utilizing a data-base and rule-base optimized through genetic algorithms, and the recorded datasets. This research employed three AI models, namely Artificial Neural Networks (ANN), Decision Tree (DT), and Random Forests (RF), using the datasets produced by the GA-tuned Fuzzy model. The objective of this study was to assess and compare the predictive capabilities of three different AI models (Artificial Neural Networks, Decision Tree, and Random Forests) in terms of predicting the values of Compression Strength and Permeability. The complete dataset was divided into two separate subsets, referred to as training data and testing data. Based on the findings, it appears that Random Forest (RF) model exhibits promising potential in accurately predicting the desired mold qualities. The model achieved a high R2 value of 0.9487, indicating a strong correlation with the target values. Additionally, the model demonstrated impressively low Mean Squared Error (MSE) and Mean Absolute Error (MAE) values of 117 and 17.6 points, respectively. Expanding the dataset size may further enhance the efficacy of the models.
2211 Improving the proportion of patients > 65 years presenting with delirium who have appropriate bloods checked within 12 hours
Authors: Marshall A , Saravanan P
Published: August 2024

Introduction

Early identification and management of all contributory factors is vital in the management of delirium. Delay in investigation can lead to morbidity, mortality, longer length of stay or inappropriate discharge from hospital. We carried out a Quality Improvement project looking to ensure all patients with delirium had appropriate blood tests taken in the Emergency Department (ED).

Methods

For the first cycle, 25 patients >65 years admitted through ED in December 2022 and January 2023 with delirium were identified based on medical clerking and post take ward round diagnosis. Patients who had a cause for confusion which was clearly known, for example sepsis, were excluded. Data analysis revealed the percentage of patients who had their calcium and CRP bloods checked within 12 hours of admission was only 20% and 76%, respectively. We introduced a simple change: adding bone profile and CRP to the ‘confusion button’ on the ICE electronic requesting and reporting system. A second cycle of data collection was completed for a further 25 patients admitted with delirium between June and July 2023 to measure the effectiveness of the implemented change.

Results

From our initial analysis, only 20% of patients aged >65 years presenting with delirium had their calcium and 76% of patients had their CRP checked within 12 hours of admission. Following our intervention, we found that 88% of patients had their calcium and 96% of patients had their CRP checked within 12 hours of admission.

Conclusion

The amendment of the ‘confusion screen’ button, on the ICE requesting system in the hospital, resulted in a significant increase in the number of patents having appropriate blood tests within 12 hours of admission.
2280 A QIP to improve pain Management in Elderly Patients presenting with falls to a&E and being referred to the OPAL team
Authors: Rahman M , Danby R , Al-Mahdi A , Gupta A
Published: August 2024

Introduction

Falls account for one of the most common and serious issues contributing to a disability, especially among elderly individuals (1). Injuries resulting from a fall range from mild to severe, but they are all usually painful (2). According to RCEM ‘Recognition and alleviation of pain should be a priority when treating the ill and injured’(3). The aim of this project was to improve pain management in patients with falls being referred to the OPAL team. Studies have shown that patients whose primary pain is well managed and treated in the ED have a higher overall satisfaction with hospital services (4).

Method

Two PDSA cycles have been completed. Initial data was collected retrospectively from 3/9/23 to 9/9/23 to gather baseline information on current practice. Data was collected from hospital patient’s electronic records. This was followed by teaching sessions and poster distribution to improve staff education highlighting ways to address pain and its management. Post intervention data was collected from 11/12/23–17/12/23. Duplicate records and non-fallers were excluded.

Result

Initial data was collected on total 75 patients which showed nearly 50% of the patients were in pain when referred to OPAL team. Among the patients in pain, OPAL team advised for pain relief in only 1/3rd of them. Following intervention, data was collected on 57 patients following exclusion. It showed only 26.3% of the patients were in pain at the time of referral, a significant improvement from nearly half in the previous cycle. Also, OPAL team advised regarding pain relief in almost all patients in pain. As a result, 79% of the patient were pain free during OPAL assessment.

Conclusion

The QIP showed importance of staff education in improving pain management in elderly patients presenting with falls. Further PDSA cycles are planned to sustain the current improvement in practice.
2347 EXPEDITE: a sustainable initiative to improve average length of stay (ALOS) in an acute geriatric Ward in Singapore
Authors: Aroos R , Hong LY , Lai SF , Wong B , Ong LM , Seow A , Ng SL , Woon E , Seetharaman SK
Published: August 2024

Introduction

Prolonged hospitalisation is associated with increased mortality, increased risk of hospital acquired infections, functional decline and institutionalisation in older adults. Baseline data collected for patients admitted to the Acute Geriatric ward of Alexandra Hospital, a tertiary hospital in Singapore, from 28 Feb to 31 Aug 2022 (n = 299, age > 65 years) revealed an average LOS of 12.3 days. Potential contributing factors identified • 98% did not have a documented medical clearance date • 3.54 days required to decide for medical social worker referral • 9 days before discharge plans are communicated to family. Aim: To reduce average length of stay (ALOS) from 12.3 days in Aug 2022 to 9.81 days by Aug 2023. This was a target set at the hospital level on our Geriatric service in the setting of a rising national pressure for inpatients beds.

Method

The EXPEDITE Huddle was a regular 30 minute huddle introduced, in addition to the existing weekly multidisciplinary meeting. It was developed based on the QI methodology and streamlined from 3x/week frequency to 1x/week following PDSA cycles. A chat group on the secure hospital mobile phone messaging system was also created for ease of communication among stakeholders.

Results

• ALOS reduced from 12.3 days to 9.1 days (3.4 days) • 91.8% of patients (n = 154) now have a documented medical clearance date • Communication on discharge plans initiated within 3 days from admission • Sustainability: -In light of positive results, a discharge care navigator (DCN) to lead the discharge planning efforts was offered by the hospital to the Geriatric service. -The EXPEDITE huddle (now led by the DCN) continues and ALOS has remained within target.

Conclusion(s)

Early discharge planning with a focus on system level factors that contribute to delayed discharge can help reduce ALOS in hospitalised older adults.
2265 Patient experience and outcome measures in virtual wards at Swansea Bay university health board.
Authors: Burgess AJ , Mehta A , Davies EK , Hapgood N , Davies EA
Published: August 2024

Introduction

Swansea Bay Health Board is covered by eight community clusters (240 virtual beds), each with their own Virtual Ward (VW) MDT which provides community based Comprehensive Geriatric Assessment and reablement. The VW governance structure includes the routine collection of person-centred metrics. There is no recognised PROM or PREM specifically designed for needs of frail older people and PROMsand PREMsare rarely used to inform quality and continuity in services at transitions of care (e.g. at discharge from hospital).

Methods

VW data from June 2023 to February 2024 was analysed. Patient-reported outcomes and experiences (PROMS and PREMS) were collected by the VW team at set timepoints in the patient journey. Data was collected using the PRO-MAPP digital interface ensuring inter-user consistency.

Results

1858 VW patients, 1094 (58.9%) female, median age 86 years. The majority, 1044 (56.2%) were referred from secondary care, primarily from acute frailty services, with the remainder identified by primary care. In total, 418 PROMS and 344 PREMS were collected. PROMS—Reported improvements in mobility, self-care, usual activities, pain and anxiety & depression (p < 0.001) after VW input. PREMS—The majority of patients found the VW had been explained well prior to referral (84.0%), were contacted promptly (95.6%), staff were professional and friendly (100%), provided patient-centred care (94.2%), staff were contactable (92.4%), were glad they avoided or reduced the length of hospital admission (95.3%). When speaking with 72 care-givers, they were happy the patients’ needs were met (100%) and the VW positively impacted their lives as carers (90.1%).

Discussion

There was high patient and care-giver satisfaction with the VW service. PROM data suggested a significant positive impact on patient outcomes. Not all the patients referred to the VW have been sampled which is a missed opportunity and there was a variability between data collection between clusters.
2143 Minimal ingredient wipes for geriatric care
Authors: Sommerville J , Taylor N , Gilligan E , Schols J
Published: August 2024

Introduction

Wipes are a practical solution for cleansing skin and widely used in children, neonates, and in geriatric care. Effective cleansing requires low liquid surface tension (<40 mN/m), and many wipes contain surfactants to achieve this [1, 2]. However, these compounds may cause dryness, itching, irritation, and inflammation [1]. Age-related degeneration in skin suppleness decreases skin viability, often leading to irritation and incontinence-associated dermatitis, especially in frail nursing home residents [3]. By utilising purification technology, it is possible to lower liquid surface tension for cleansing and mitigate negative skin reactions caused by surfactants and additives. One minimal ingredient surfactant-free wipe (SF-wipe) achieves a solution surface tension of <35 mN/m, facilitating effective cleansing without surfactants [2]. These SF-wipes demonstrated superior results in a prospective study where neonates experienced significantly fewer days of clinically significant irritant diaper dermatitis [4]. The aim of this exploratory study was to understand current behaviours around personal hygiene and attitude towards SF-wipes in nursing homes.

Method

Four nursing care homes (n = 71 residents) received SF-wipes to trial. Feedback on effects and usability was gathered through interviews and reported qualitatively.

Results

Nursing staff indicated that the SF-wipes were soft, non-drying, non-abrasive, and facilitated faster in-bed bathing versus previous methods. Using SF-wipes did not lead to skin irritation in most residents, though some experienced transient skin coldness after use.

Conclusions

The high prevalence of skin conditions like incontinence-associated dermatitis in nursing home residents [5] means SF-wipes may prove beneficial versus surfactant-containing wipes, mirroring findings in neonates. Further studies are needed to prove this.

References

[1] Liu L. J Cosmet Sci. 2020;71(2):91–109; [2] WaterWipes data on file; [3] Hurlow J and Bliss DZ. Geriatr Nurs. 2011;32(4):257–62; [4] Price A, et al. Pediatr Neonatol. 2021;62(2):138–45; [5] Völzer B, et al. Int J Nurs Stud. 2023;141:104472.
2254 Improving the quality and breadth of advance care planning discussions on gerontology wards in an acute London trust
Authors: Curtis T , Crabtree S , Al-Hashimi S , Hasan S , Osborne G
Published: August 2024

Introduction

Advance care planning (ACP) offers people the opportunity to plan their future care whilst they have capacity to do so and is supported by national guidance. Decisions regarding future care are more likely to be individualised and holistic when patients and their significant others are involved. This QI project aimed to address this by increasing the frequency of ACP discussions being offered and recorded on gerontology wards in an acute London Trust.

Method

A multi-professional steering group was established to improve ACP using PDSA methodology. A new ACP toolkit, training programme and electronic flowsheet (within the hospital’s patient record system) were implemented. ACP documentation quality was audited on gerontology wards pre and post implementation (over one to four months respectively). Data was compared using Pearson’s Chi-squared test.

Results

ACP flowsheets were completed by junior and senior doctors, and clinical nurse specialists in frailty and palliative medicine. The initial audit found disparity between documented topics of ACP conversations, with cardiopulmonary resuscitation recommendations being most discussed. Post implementation, 24 ACP flowsheets were reviewed, showing that more ACP topics were documented where these conversations were had; preferred place of death increased from 24% to 60% (p 0.011); treatment escalation plan increased from 41% to 75% (p 0.014); preferred place of care increased from 59% to 71% (p 0.066). Topics not showing significant improvement in documentation (despite inclusion in the flowsheet) were spiritual needs, information needs and prognostic discussion, broader social needs and what was most important to the patient.

Conclusion

The implementation of an electronic ACP flowsheet improved documented ACP conversations in some topics, guiding healthcare professionals to deliver care that aligns with peoples’ wishes and preferences. Documented conversations became easier to access, review and audit. Work is still needed to promote ACP conversations being centralised around what matters most to patients.
2145 Physical and mental health needs of older transgender adults in the U.K.: a scoping review
Authors: Knox C , Wells L , Shrewsbury D , Levett T
Published: August 2024

Introduction

The number of adults in the UK who identify as transgender is increasing, through greater recognition of trans identity and growing numbers of individuals transitioning in later life. The term ‘Transgender’ encompasses a diverse range of experiences and identities, including those who identify as non-binary, gender-fluid, and gender-queer. However, within this review, we use the shortened term ‘trans’ and the following broad definition: ‘people whose gender is different from the gender assigned to them at birth.’ We conducted this exploratory review to examine the literature regarding the specific health and social care needs of older trans adults.

Methods

We utilised scoping review methodology and thematic qualitative analysis to systematically search and map the literature related to the physical and mental health challenges related to the ageing experience among trans adults in the UK.

Results

We identified 22 relevant papers through combined systematic search and additional manual reference review. We recognised five key themes within the literature: Systems and Structural Factors, Health and Mental Health, Social Care, Diversity and The Future. The former three themes relate to limitations presented by current models of care, barriers within services and potential areas for development. Key areas identified include challenges related to the application of a binary gender model within healthcare systems as well as advanced care planning and ensuring gender-affirming care where capacity is lost including living with dementia. The latter two themes identify gaps in the current literature and provide examples of trans-inclusive positive practice.

Conclusions

There is an ongoing need for researchers, clinicians and policymakers to ensure that the needs of older trans adults are studied, understood and accommodated within policy and practice. Service providers delivering care to older adults must understand trans-specific needs, particularly around advanced care planning, to ensure that trans people are supported to age well.
2168 A survey of non-consultant hospital doctors’ perspectives, knowledge, and practices towards delirium in a large Irish hospital
Authors: Hassabo M , McCluskey P , Browne J , Ntlholang O
Published: August 2024

Background

Delirium is a common condition in hospitals, especially among older people. This refers to a dramatic decline in mental capabilities marked by diminished concentration and consciousness.

Aims

The purpose of this study is to assess the views, knowledge, and behaviour of non-consultant hospital doctors about managing delirium in a large Irish hospital.

Methods

Questionnaires were given to 28 healthcare professionals from various departments according to Davis and MacLullicin (2009). It was conducted between July and September 2023 with emphasis on finding out its prevalence rate, diagnostic criteria, and management strategies for delirium.

Results

The study established that majority of the respondents recognised the importance of delirium but there appears to be a gap in practical management of this clinical syndrome. Although many doctors agreed that delirium was significant, most lacked confidence in diagnosing as well as managing it. The use of standardised assessment tools like the 4AT was limited.

Conclusions

This study highlights the disparity between what is known and practiced by hospital doctors concerning delirium care. It implies increased training for delirium management with frequent use of assessment tools and ongoing education aimed at enhancing patients’ outcomes during cases of delirium.

Keywords: Delirium Management, Hospital Doctors, Medical Training, 4AT, Clinical Practice, Elderly Care.
2233 Incidence of inappropriate CPR in the emergency department—is ReSPECT making a difference?
Authors: Lisseter A
Published: August 2024

Introduction

A BMJ study suggested that 1 in 5 sick, older patients have a ‘do not resuscitate’ document and a large proportion only had this completed in the Emergency Department (ED) (1). Current ED pressures could cause greater delay in this discussion, resulting in inappropriate cardiopulmonary resuscitation (CPR). The ReSPECT form was established to bring consistency to the communication of patients wishes, including ‘do not attempt CPR’ (DNACPR) (2). This QUIP assessed the incidence of inappropriate CPR in two ED’s by investigating the proportion of CPR performed on those with a prior DNACPR or ReSPECT form.

Method

Data was collected retrospectively from cardiac arrests in two ED’s between the 1st of January 2023 and the 17th of November 2023. The three parameters assessed were the number patients undergoing CPR, number with prior DNACPR/ReSPECT forms, and how often CPR occurred within 30 minutes of patient arrival. Hospital A used ReSPECT forms, whereas Hospital B did not.

Results

Over the assessed period, CPR was performed on 21 patients at Hospital A. Of these, 19% had prior DNACPR/ReSPECT forms and 43% of CPR was within 30 minutes of patient arrival. 10 patients received CPR at Hospital B. Of these, 0 patients had prior DNACPR/ReSPECT forms and 40% of CPR occurred within 30 minutes of patient arrival.

Conclusion

Hospital A performed CPR on more patients with prior DNACPRs compared to hospital B. Occasionally, these DNACPRs were on the GP portal but were not easily accessible in the hospital setting due to the hospital’s paper-based notes system. Both sites performed CPR on a similar proportion of patients within 30 minutes of admission. This highlights the importance of prompt decisions, communication and the need for community discussion with documentation that is easily accessible across healthcare settings.
2279 Experiences of healthcare staff in an acute hospital-nursing home collaboration: a quantitative study
Authors: Ong CY , Liew YH , Lim XYS , Lee MHJ
Published: August 2024

Introduction

We implemented an acute hospital-nursing home collaborative pilot in two nursing homes with an objective to reduce emergency department visit and inpatient hospitalisation among nursing home residents. We aim to study the experiences of the healthcare staffs from the two nursing homes.

Method

Focus group discussions using semi structured interview guide were conducted on 26 nursing home staffs who have had experience in using the collaboration intervention. Transcripts were analysed using qualitative interview analysis.

Results

Five main domains were explored: knowledge and understanding; service satisfaction; challenges; enablers; and service improvements. Most of the ground staffs had incomplete grasp of the purpose and logic of the collaboration. However, the consensus obtained were that they felt reassured knowing they could consult hospital providers easily without activating emergency services immediately. Nursing home staffs also acknowledged having equipped themselves with skills to identify residents who required escalation of care. Interventions used such as NEWS assessment tool, hospital transfer forms and teleconsultation portal were found to be easy to use. Among the challenges faced on the ground were pressure by next-of-kins, nursing staffs’ lack of confidence, additional tasks of filling up pre-conveyance information. One of the key enablers is the motivation of staffs to improve patient care at nursing home. Increasing staffing, continuous training, and skills training were among aspects suggested for collaboration improvement.

Conclusion

Healthcare providers in nursing home faced adaptation issues during the initial pilot of the collaboration; nevertheless, they were in agreement that the collaboration is helpful for better patient care.
2283 Early supported discharge for fragility fractures -collaborative working to deliver responsive high quality patient-centred care
Authors: Davies EK , Beynon-Howells CJ , Burgess AJ , Mehta A , Ng K , Davies EA
Published: August 2024

Introduction

During 2022, non-femoral fractures that didn’t require operative management had 30 days median inpatient length of stay (LOS) at SBUHB. Femoral fracture patients >65 years had LOS 36 days (GIRFT average 19 days), with 720 admissions. High local incidence is believed to be contributed by historical failures to identify and treat non-femoral fragility fractures. A new service was created from a collective effort to do better for our patients and prevent avoidable harm by breaking down barriers between services and promoting effective collaborative working.

Methods

A collaboration between the following key services was formed:-.

1. Older Persons Assessment Service (OPAS) -identify fragility fractures presenting to ED 2. Orthogeriatrics -identify suitable femoral fracture patients.

3. Physiotherapy -early assessment and transfer to reablement into the community.

4. Virtual Wards –ongoing CGA and reablement in the community.

Additional resource was secured to provide short-term bridging of care and community therapy input. Data was prospectively collected and included demographics, site of fracture, referrer and LOS.

Results

From March 2023, the service identified 457 patients, 312 (68.7%) Female, median age 86 years. 157 (34.6%) patients had a femoral fracture and 300 (65.4%) were non-femoral fragility fractures, majority identified by OPAS, with 206 (68.7%) being discharged same day. Overall, admission was avoided in 207 (45.3%) patients and 247 (54.6%) had an early discharge/reduced LOS with 3(0.1%) re-admissions avoided. The mean LOS on discharge is 6.6 days with a calculated monthly bed saving of 13.9 days across the service.

Conclusion

Collaborative working has created an early supported discharge pathway. Femoral fracture patients are discharged earlier, some 3 days post-op, with the necessary support to continue reablement at home. Fragility fractures are identified at the front door and offered same-day discharge with ongoing comprehensive geriatric assessment and reablement within the virtual wards with positive feedback from patients and their families.
2306 Bone health after hip fracture; does introducing a 10-day vitamin D loading regime increase use of inpatient intravenous zoledro
Authors: Devlin R , Alio Z , Brown M , Chalmers K , Rashid A
Published: August 2024

Background

Patients who experience a hip fracture have a high re-fracture risk. Prompt initiation of anti-osteoporosis treatment is therefore vital. Oral bisphosphonates are less well tolerated in some older people resulting in poor adherence. A single dose of IV zoledronate however, can be effective for up to 3 years and is shown to reduce fracture rate by 35% (Gregson, Age and Ageing, Vol 51, 2022).

Aim

To increase use of IV zoledronate post hip fracture in Salford Royal Hospital Local barriers: a trust guideline advising a 7-week vitamin D loading regime means inpatient IV zoledronate post hip fracture is limited. Waiting time for outpatient parental therapy is >6 months.

Intervention

A new trust wide guideline was written, approving rapid vitamin D loading over 10 days post fragility fracture to promote IV zoledronate use.

Methods

Retrospective analysis of case notes for 100 patients admitted with hip fracture at baseline (August 2021) and after the intervention (August 2023). We recorded FRAX recommendation, bone health plan on discharge and osteoporosis treatment implemented.

Results

There was an increase in inpatient zoledronate use to 16% (5% at baseline). Oral bisphosphonate use reduced to 10% (28%). There was 98% adherence to the new rapid vitamin D loading regime. In cycle 2, 6% of patients did not receive planned IV zoledronate as discharged before vitamin D loading completion. 2% did not receive planned IV zoledronate despite vitamin D loading complete.

Conclusions

Rapid vitamin D loading allowed more patients to receive inpatient IV zoledronate post hip fracture. There is scope to increase this further. Future plans include adding ‘date for IV zoledronate’ to the electronic notes template and including bone health in the pre-weekend check list to minimise delay in IV zoledronate administration.
2320 DNAR: all or nothing: impact of education sessions Re-audit
Authors: Ramjohn J , Kelly J , Abdalla A , Hamad A , Carvalho J , Gibbons C , Quigley L , Finan K
Published: August 2024

Introduction

Do Not Attempt Resuscitation (DNAR) orders are implemented to obviate inappropriate Cardio-Pulmonary Resuscitation (CPR) in patients with low chances of survival post-CPR. However, ambiguity regarding ceilings of care for patients with a DNAR order can arise. This re-audit aimed to review DNAR and ceilings of care documentation according to national Irish Health Service Executive (HSE) guidelines after education sessions in a Model 3 Hospital.

Methods

A point-prevalence chart review of thirty-one adult medical inpatients with a DNAR order was conducted after two education sessions were held for Non-Consultant Hospital Doctors (NCHDs) and Consultants.

Results

Of all thirty-one charts, 35% documented DNAR status in the medical notes, with 32% documenting the reasoning for DNAR status, both unchanged from the first audit cycle. There was an increase in documentation of patient discussion (61% versus 45%) and reasons if this was excluded (66% versus 41%). There was no change in documentation of patient relatives’ discussion (48%) but there was an increase in the reasons if this was excluded (25% versus 18%). There was an overall increase in ceilings of care documentation for ICU admission (three-fold increase), intubation (two-fold increase), inotropic support, and comfort measures, but rates of documentation were still less than 15%.

Discussion

This audit elucidates the efficacy of education sessions in improving DNAR documentation adherence. Recent studies have highlighted uncertainty among NCHDs regarding treatment escalation in acutely unwell patients in the absence of adequately filled DNAR orders and clear documentation of ceilings of care. We posit the introduction of a Ceilings of Care document, akin to the United Kingdom’s Medical Advance Plan.

Conclusion

Accurate recording of DNAR status and ceilings of care is essential for quality care and treatment escalation. While simple education strategies have proven beneficial in enhancing compliance, additional efforts are needed to enhance ceilings of care documentation.
2269 Preventing frailty crises: improving the care of frail patients in an acute hospital Ward setting
Authors: Dhaliwal TK , Teng RSY , Tan-Pantano RT , Oo TD , Barrera VC , Espelata WDV , Teoh SN , Semeniano G , Li F , Conroy S , Rosario BH
Published: August 2024

Introduction

Frailty is common in hospitalised older patients and hospitalisation can lead to negative outcomes. Our study aimed to provide insights into current decision-making processes on treatment, care and discharge by clinical teams.

Methods

We conducted a prospective cohort study in frail older patients ≥65 years old admitted to acute medical and surgical wards. Clinical Frailty Scale ≥5 was used to identify frail patients and process mapping was undertaken to identify common themes, trajectories and potentially modifiable factors. We followed patient journeys from admission to discharge and examined factors contributing to longer hospitalisation. We documented existing processes, environmental, system and clinical factors influencing patient care. Comprehensive geriatric assessments identified underlying geriatric syndromes and where gaps in management were identified, we recommended frailty interventions.

Results

Fifteen patients provided informed consent, of whom 73% were female and average age 80 years, ranging 69–95 years. 67% were frail (CFS 5–6) and 33% were severely frail (CFS 7–9). Most patients were sarcopenic with a SARC-F score of ≥4 and had functional and gait impairment. 60% were underweight (BMI <22). Process mapping revealed gaps in frailty-focused care and included delayed transfer to acute wards, delayed investigations, and multiple unidentified geriatric syndromes which were prevalent in this cohort. Patients fell into three broad groups, short (1–6 days), intermediate (7–14 days), or long (>14 days) length of stay and delays in discharge-planning were common, mean of 4.17 days, as were delays in identification of a caregiver. Recommendations for community support services were provided to >50% patients.

Conclusion

Our study shows that mapping the frail patient’s journey can identify gaps in existing processes and opportunities for improvement and collaboration. Integrating geriatric care into general wards could improve patient outcomes. We aim to use this work to guide frailty-attuned care for hospitalised older patients.
2271 Older trauma in the emergency department
Authors: Tometzki B , Harbinson C , Hammond J , Vaughn C
Published: August 2024

Aim

Improve the care of patients aged 65+ presenting with trauma to the emergency department by ensuring earlier senior reviews (ST4+) and consideration of trauma calls and appropriate imaging.

Method

Staff survey to assess awareness of older trauma and its management. Data analysis and collection followed by use of PDSA cycles to implement change. Teaching session on primary survey assessment and management of older trauma. Development of older trauma standard operating procedure.

Results

Improvement was seen in both primary outcomes over a period of 8 months. Documentation of primary survey improved from 30% from the initial 5 weeks to 52% over the final 5 weeks on average. Senior doctor review or discussion improved from 30% average in the first 5 weeks to 80% averaged across the final 5 weeks. There was no evidence of effect on waiting times in the emergency department for these patients.

Conclusion

This quality improvement initiative has positively impacted the early assessment of older trauma patients, aiming to mitigate the likelihood of missed injuries and adverse outcomes. While we haven’t formally assessed more complex outcome data, a notable achievement is the initiation of a cultural shift among our frontline medical and nursing staff. This shift involves approaching older trauma patients with a heightened index of suspicion. Among the interventions, the most straightforward and reproducible was the implementation of regular educational emails. We anticipate continued progress and hope that this poster serves as inspiration for other departments. Encouraging a review of how they assess and treat this expanding cohort of vulnerable, complex, and potentially critically ill patients. Unfortunately, it is not uncommon that for our growing elderly population, a trip and fall can lead to fatal consequences. We aspire for this work to contribute towards broader efforts in changing that narrative.
2329 A quality improvement project to improve bone health plan in trauma and orthopaedic discharge summaries
Authors: Perera H , Cannon A
Published: August 2024

Introduction

In 2022, 293 hip fractures had been admitted to the Bristol Royal Infirmary. As recommended by National Osteoporosis Guideline Group (NOGG) intravenous zoledronate is the first line treatment option following a hip fracture.

Aims

We wanted to improve bone health summaries on discharge summaries for the benefit of the General practitioner (GP), Fracture liaison service and patient.

Results

We used our local National Hip Fracture database to identify the patients who had had a fractured hip in September 2023. We then introduced our changes as part of the PDSA cycle. The change was copying and pasting a blank bone health paragraph into every discharge summary on day 1 of the patient’s admission to make it easier for the Trauma and Orthopaedic (T&O) junior doctor completing the discharge summary pre discharge. We then used an excel spreadsheet to collect results in September and October 2023 and analyse them and display them using pie charts. In September, 28.3% of discharge summaries did not have a bone health plan, compared to 25% in October. Not mentioning of Vitamin D levels in discharge summaries has increased from 57.1% to 59.4%. Mentioning of administration of inpatient zoledronic acid post fracture decreased from 32.1% to 25%.

Conclusion

Despite the intervention, the bone health plans are poorly communicated to the GP and the Fracture Liaison service, which leads to delay in administering bone health medication in a timely manner to prevent a second fracture.

Next step

Teaching Session with the T&O juniors to find out if they think it’s a good idea and discuss why they have not found the current standardised paragraph helpful. Then we can work together to make a further change (s) and start another PDSA cycle.

References

National Osteoporosis Guideline Group.UK (NOGG),2021.
2236 Emergency department attendance stratified by cause and frailty status: a national cohort study of over 155 million patients
Authors: Sokhal BS , Matetić A , Protheroe J , Helliwell T , Myint PK , Paul T , Mallen C , Mamas M
Published: August 2024

Introduction

Data are limited on whether the causes of Emergency Department (ED) attendance and clinical outcomes vary by frailty status.

Methods

Using data from the Nationwide Emergency Department Sample, all ED attendances from 2016 to 2018 were stratified by the cause of attendance and Hospital Frailty Risk Score (HFRS) category. Logistic regression was used to determine adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) of ED and overall mortality.

Results

A total of 155,497,048 ED attendances were included, of which 125,809,960 (80.9%) had a low HFRS (<5), 27,205,257 (17.5%) had an intermediate HFRS (5–15) and 2,481,831 (1.6%) had a high HFRS (>15). The most common cause of ED attendance in the high HFRS group was infectious diseases (43.0%), followed by cardiovascular diseases (CVD) (24.0%) and respiratory diseases (10.2%). Musculoskeletal diseases were the most common cause of admission for the low HFRS group (21.2%), followed by respiratory diseases (20.6%), and gastrointestinal diseases (18.5%). On adjusted analysis, high HFRS patients had increased overall mortality (combined ED and in-hospital) across most attendance causes, compared to their low HFRS counterparts (p < 0.001). High HFRS patients with infectious diseases (aOR 23.88 95% CI 23.42–24.34), CVD (aOR 2.58 95% CI 2.55–2.61) and respiratory diseases (aOR 36.90 95% CI 36.18–37.62) had an increased risk of overall mortality, compared to their low-risk counterparts (p < 0.001).

Conclusions

A significant proportion of patients attending the ED are frail, with the cause of attendance varying by frailty status. Frailty is associated with increased overall mortality across most attendance causes.
2243 Modification effect of disability profiles on the association of blood pressure and mortality among older long-term care people
Authors: Zhong Y , Feng C , Hou L , Yang M , Zhang X , Wu J , Dong B , Jia P , Yang S , Dou Q
Published: August 2024

Introduction

Evidence of the optimal blood pressure target for older people with disability in long-term care is limited. We aim to estimate the associations of blood pressure with all-cause and cause-specific mortality in older people with different profiles of disability.

Methods

This prospective cohort study was based on the government-led long-term care program in Chengdu, China, including 41,004 consecutive disabled adults aged ≥60 years. The association between blood pressure and mortality was analysed with doubly robust estimation, which combined exposure model by inverse probability weighting and outcome model fitted with Cox regression. The non-linearity was examined by restricted cubic spline. The primary endpoint was all-cause mortality, and the secondary endpoints were cardiovascular and non-cardiovascular mortality.

Results

The associations between systolic blood pressure (SBP) and all-cause mortality were close to a U-shaped curve in mild–moderate disability group (Barthel index ≥40), and a reversed J-shaped in severe disability group (Barthel index <40). In mild–moderate disability group, SBP < 135 mmHg was associated with elevated all-cause mortality risks (HR 1.21, 95% CI, 1.10–1.33), compared to SBP between 135–150 mmHg. In severe disability group, SBP <150 mmHg increased all-cause mortality risks (HR 1.21, 95% CI, 1.16–1.27), compared to SBP between 150–170 mmHg. The associations were robust in subgroup analyses in terms of age, cardiovascular comorbidity and antihypertensive treatment. Diastolic blood pressure (DBP) < 67 mmHg (HR 1.29, 95% CI, 1.18–1.42) in mild–moderate disability group and < 79 mmHg (HR 1.15, 95% CI, 1.11–1.20) in severe disability group both demonstrated an increased all-cause mortality risk.

Conclusion

The optimal blood pressure range was higher in older long-term care people with severe disability than those with mild–moderate disability. This study provides new evidence for optimal individualised management of blood pressure in disabled older people in long-term care settings.
2239 Making frailty practice robust – using e-learning to facilitate frailty education
Authors: McKeown W , Bhatt K , Collingridge G , Gyimah C
Published: August 2024

Introduction

Frailty is a condition with increasing prevalence in the UK and significantly impacts the lives of those affected and their families. Frailty is a condition best managed by teams of skilled multi-disciplinary health and social care professionals (HSCPs). It is therefore essential that all HSCPs working with older people living with frailty are equipped with the appropriate knowledge and attitudes to look after affected persons.

Methods

In 2023, The British Geriatric Society (BGS) and NHS England (NHSE) collaborated to produce an online e-learning programme aligned to tier three of the NHS Skills for Health Frailty framework of core capabilities. The e-learning programme was launched in September 2023 and was made available for free to all who signed up. It contained four modules: Understanding and Communicating Frailty, Identifying Frailty, Supporting People Living with Frailty and Building Systems Fit for Frailty. Learning was provided through case-based discussions, best practice examples and input from the full range of HSCPs who now deliver frailty care.

Results

Between September 2023 and January 2024, over 4000 HSCPs registered for the online module. A wide range of HSCPs signed up for the module with nursing staff, advanced clinical practitioners, consultant geriatricians and physiotherapists, being the groups most commonly represented. 92% of those who completed the module agreed or strongly agreed that the course helped develop knowledge, understanding and confidence in frailty. 91% of those who completed the module said completion of the course would help them to further improve patient care and clinical practice. Areas identified to enhance the module further included addition of more case studies and making the resource more adaptable to all UK regions.

Conclusions

e-Learning can be an effective facilitator of frailty education for a wide range of HSCPs. Ongoing review of learner feedback should be undertaken to inform future programme updates.