bluuebunny/crossref_metadata_2025 huggingface dataset:
38 Dementia, Apoe and COVID-19 Severity
Authors: Masoli J , Kuo C L , Atkins J , Pilling L , Delgado J , Kuchel G , Melzer D
Published: March 2021

Introduction

During the COVID-19 pandemic, pre-existing dementia was associated with a 3x increase in risk of hospitalisation and (25.6%) of COVID-19 related deaths had dementia. However, it is unclear whether people living with dementia are at higher risk of COVID-19 due to dementia or whether there may be a biologically plausible link between dementia and COVID-19. The ApoE e4 allele is highly associated with dementia. We aimed to test the COVID-19 risk associated with dementia and the association between ApoE e4e4 allele and COVID-19 with the aim of clarifying biological vulnerability.

Methods

UK Biobank (England) participants baseline (2006 to 2010), plus secondary care data to 2017. Separate analysis tested dementia and ApoE genotype association with COVID-19 status (16th March-31st May 2020) or mortality (to March 31, 2020, plus incomplete deaths from April, 2020) in logistic models, adjusted for demographics and technical covariates.

Results

In 269,070 participants aged 65+, including 507(0.2%) hospitalized COVID-19 patients, those with pre-existing dementia were at increased risk of being hospitalized for COVID-19 (OR = 3.50 95% CI 1.93 to 6.34) and also for COVID-19 and death (OR = 7.30 95% CI 3.28–16.21). In 375,689 European-ancestry UKB participants, ApoE e4e4 homozygotes were more likely to be COVID-19 test positives (reaching genome-wide significance: OR = 2.24, 95% CI:1.72–2.93, p = 3.24 × 10–9) and of mortality with test-confirmed COVID-19 (OR = 4.29, 95% CI: 2.38–7.72, p = 1.22 × 10–6), compared to e3e3s homozygotes. The associations were little changed in subsets of participants who were free of diseases associated with ApoE e4 and COVID-19 severity.

Conclusion

Dementia was found to be disproportionally common in older adults who develop severe COVID-19. We have shown a plausible genetic pathway of increased COVID-19 risk with dementia, therefore suggesting that the positive association between dementia and COVID-19 is not just the result of high cases of COVID-19 in care homes.
44 Improving Discussions Around Treatment Escalation Decisions in Patients with Subdural Haematomas on A Neurosurgical Ward
Authors: Haire E , Kimpton G
Published: March 2021

Background

It is becoming increasingly accepted that discussion and documentation of patient wishes and clinical decisions regarding treatment escalation planning are an essential part of patient care. Following the Tracey judgement, it became a legal requirement, rather than a recommendation, for doctors to involve patients and their families in DNAR decisions.

A previous audit in the neurosurgical department found a high prevalence of patients at risk of deterioration with little evidence of attempt to discuss or document treatment escalation decisions (TEDs).

Aims

Methods

We conducted surveys of the multi-disciplinary team within the neurosurgical department to gain a better understanding of their opinions about the current discussion and documentation of TEDs in the department. These contained a mixture of rating scales and free text answers. Following this we engaged senior staff in plans to improve this by introducing these discussions to governance meetings and educated all members of the ward using e learning and tea trolley teaching.

Results

Amongst 18 healthcare professionals, 12 felt patients did not have clear TEDs. Ten felt discussions were not appropriately timed. Response themes included feeling unsupported, poor timing of conversations and low quality documentation. Following this a consensus decision from the consultant body mandated documentation of TEDs in patients presenting with chronic subdural haematomas. We have worked closely with the national ReSPECT programme and established the neurosurgical ward as a lead for the introduction of the new form.

Conclusion

The neurosurgery department is now at the forefront of the move to improving discussions and documentation about patient wishes in the Trust. Additionally, we have opened the conversation within the multi-disciplinary team and provided training and education about the importance of TEDs.
141 Face Time’ for the First Time: Patients, Families and Junior Doctors
Authors: White H , Tuck A , Pyrke B , Murphy E , Figg K , Cartwright G , Abdalla B
Published: March 2021

Introduction

Over the course of the COVID-19 pandemic, supporting effective communication between patients and their families has been a recognised challenge in the healthcare environment. Virtual communication via telecommunication and video-calling is more important than ever, but with minimal clinician education, preparation and relevant technological infrastructure available in the context of a global pandemic, we have recognised communication as an area for improvement as junior doctors working on a COVID-19 ward.

Methods

We interviewed via telephone 22 nominated next of kin relatives of patients admitted to a COVID-19 ward in the University Hospital of Llandough during May 2020 using a pre-prepared survey. We then provided relatives with the opportunity to engage with video-call updates from a doctor (with the patient’s permission). In appropriate scenarios, we used video calling to break bad news and to facilitate difficult communications with family members. These video calls were provided via Accurx, an NHS approved video communication system.

Results

Initial survey results showed an average understanding score of their relative’s current clinical plan of 5.5/10, with 63% of respondents saying they did not feel well informed. Nearly a quarter of respondents (22%) had received difficult news over the phone during the COVID-19 pandemic, and 86% said they would find video communication useful. Post-intervention survey results suggested a unanimous improvement in relative satisfaction, with relatives reporting an increased understanding around the admission, reassurance around the quality of care being given and less isolation from the patient.

Conclusions

The COVID-19 pandemic has provided novel communication challenges to physicians, promoting flexibility and adaptation to some of the core inter-personal skills we develop throughout training. Technology plays a huge role in this, and the use of video calling in particular can preserve non-verbal communication within the doctor-relative relationship and improve emotional connection between patients and their loved ones.
148 Lipid Targeting Post-Stroke—Targeting Who?
Authors: Micallef C , Bingham K , Barber J M
Published: March 2021

Introduction

Frailer patients are at high risk of complications from drugs like statins. Other less frail patients may be undertreated. The Treat Stroke to Target trial showed that high risk patients with atherosclerosis and/or ischaemic heart disease (IHD) who were treated to an LDL level of less than 1.8 mmol/L had a 22% relative risk reduction in major cardiovascular events compared to those with a higher target. In our Quality Improvement.

Project

We estimated the numbers of post-stroke cases who might safely benefit from a targeted, pharmacist led intensive lipid management program.

Methods

500 consecutive ischaemic stroke cases with a modified Rankin score (mRS) of 0–3 were identified from the Scottish Stroke Care Audit Database. Those discharged to long term care or dead at the time of data collection were excluded. Data collected was age, evidence of atherosclerosis on vascular imaging, co-morbid IHD, LDL at index admission and between 1 month to 1 year post-stroke, anti-lipid treatment at discharge and up to 1 year post-stroke. Atrial fibrillation patients were included if other risk criteria were met.

Results

The mean age of the 500 cases was 70. From this group, 297 (60%) met the entry criteria for “Treat to Stroke Target”. 190 (64%) cases had LDL checked post-discharge. 87 cases failed to reach the RCP Stroke Guidance of a 40% reduction in LDL Cholesterol. 66 (22%) of cases had LDL >1.8 mmol/L on most recent check and potentially should have been treated to target. Of the 83 cases excluded due to mRS >3 or significant dependency, 70 cases (84%) were discharged on a statin and importantly 34 (48%) of these died within 1 year of their stroke.

Conclusions

Based on annual stroke admissions in our health board, around 86–117 high risk patients could benefit from a virtual lipid treatment intensification clinic.
161 Does the Weather Contribute to Admissions of Neck of Femur Fractures?
Authors: Koizia L J , Dani M , Brown H , Lee M , Fertleman M B
Published: March 2021

Introduction

The effects of weather on overall mortality are well documented. Anecdotally, icy conditions are perceived to result in more falls and admissions for neck of femur (NOF) fractures. The aim of this unfunded pilot study was to determine whether relationships could be extracted or at least not ruled out by analysing a small dataset, and so give impetus to a larger project.

Methods

Seven trauma units across north west London were identified and NOF fracture data extracted for five years. Visual inspection of the time series, consideration of the weather on specific days and correlation analysis were used to assess causal links between fracture numbers and a variety of weather parameters (temperature, rainfall, wind and ice risk).

Results

Overall, 10,929 individuals with hip fractures were admitted over the five-year period. The highest number of admissions in a day was 14. No clear association was found between a weather parameter and daily admissions. However, when accumulated to a weekly timescale, a negative relationship with maximum temperature was found. No seasonal cycle was detected.

Conclusion

The lack of a daily relationship and presence of a weekly relationship points to a possible delayed response to weather or insufficient daily data to extract a signal. The inconclusive results also indicate that more socioeconomic data will need to be used in future studies, requiring a larger data sample. In addition, even in cold weather an urban environment may not create icy conditions, being ameliorated by the heat island effect and gritting.
52 I’m on the Floor and Can’t Get up and it’s Really Annoying: A Qualitative Investigation of Patient and Staff Perceptions of Options for Getting up From the Floor Following A Fall
Authors: Swancutt D , Hope S V , Kent B , Robinson M , Goodwin V
Published: March 2021

Background

Falls are the most common reason for ambulance call-outs resulting in non-conveyance. Even in the absence of injury, only half of those who have fallen can get themselves up off the floor. Many remain there for over an hour, increasing complications risks.

It is feasible to teach people techniques to help get themselves off the floor, yet these techniques are rarely taught. To date, there are no published data on attitudes towards teaching and learning these techniques. Our study aimed to investigate patient, carer and staff attitudes towards seeking help and using techniques to get-up following a fall.

Methods

A qualitative focus group and semi-structured interviews were conducted with 28 participants, including community-dwelling older people who had experienced a non-injurious fall, carers, physiotherapists, occupational therapists, paramedics and community first responders.

Data were transcribed and analysed systematically using the Framework approach. A stakeholder group of falls experts and patients advised during analysis.

Results

The data highlighted three areas contributing to an individual’s capability to get-up following a fall: the environment (physical and social); physical ability; and degree of self-efficacy (attitude and beliefs about their own ability). These factors influenced each person’s capability to manage their fall response.

Staff described how they balance their responsibilities, prioritising the individual’s immediate needs; this leaves limited time to address capability in the aforementioned three areas. Paramedics, routinely responding to falls, only receive training on getting-up techniques from within their peer-group. Therapists are aware of the skillset to breakdown the getting-up process, but, with limited time, select who to teach these techniques to.

Conclusion

Neither therapists nor ambulance service staff routinely teach all those at risk of falling strategies on how to get-up. Interventions to positively impact on capability to get-up following a fall should include strategies that address the environment, physical ability and self-efficacy.
59 Improving the Identification and Management of Delirium in Older Surgical Patients
Authors: Baguneid C L , Millington K L , Pattinson J , Ogden G , Malcolm F , Gordon A L
Published: March 2021

Local Problem

A multidisciplinary team comprising a consultant geriatrician and nurse consultant reviews all patients aged ≥70 years who have an emergency laparotomy at Royal Derby Hospital. Anecdotally there is a high incidence of delirium but retrospective casenote audit found only 19% of patients admitted for emergency laparotomy July 2018–July 2019 were identified as having delirium by the surgical team.

Method

A first PDSA cycle showed that the 4AT was feasible for use by healthcare assistants on the surgical assessment unit (SAU). A second PDSA cycle, described here, sought to develop a rationale for implementation of the 4AT as part of surgical assessment by comparing true prevalence of delirium using 4AT, with the prevalence detected using methods currently mandated by our hospital. All patients aged ≥65 years admitted as part of the surgical pathway had 4AT completed by a member of our improvement team on admission, with daily review until discharge.

Results

Data were collected for 111 consecutive emergency surgical admissions. Mean (SD) age was 78.3 (7.7) years. Of these, 1 and 3 were categorised as having delirium and dementia respectively using existing hospital screening tools. Using 4AT, 36 (32%) of patients were identified as having delirium. When supplemented by clinical history, true prevalence was 40 (36%). Average (SD) length of stay was 7 (5.6) days for the whole cohort, 10 (6.5) and 5.3 (4.3) days for those with and without delirium respectively.

Conclusions

4AT was 92% sensitive for delirium in our cohort. The existing hospital tool was underutilised to the point of being useless. Patients with delirium had a longer length of stay. We have developed a modified 4AT paper tool and training materials and are now piloting routine use in SAU.
81 Integrating A Front Door Frailty Service in the Emergency Department: Results of A Pilot Study
Authors: Dunnell L , Shrestha A , Li E , Khan Z , Hashemi N
Published: March 2021

Introduction

Increasing old age and frailty is putting pressure on health services with 5–10% of patients attending the emergency department (ED) and 30% of patients in acute medical units classified as older and frail. National Health Service improvement mandates that by 2020 hospital trusts with type one EDs provide at least 70 hours of acute frailty service each week.

Methodology

A two-week pilot (Monday–Friday 8 am-5 pm) was undertaken, with a “Front Door Frailty Team” comprising a consultant, junior doctor, specialist nurse and pharmacist, with therapy input from the existing ED team. They were based in the ED seeing patients on arrival, referrals from the ED team and patients in the ED observation ward—opposed to the usual pathway of referral from the ED team to medical team. Data was captured using “Cerner” electronic healthcare records. A plan, do, study, act methodology was used throughout with daily debrief and huddle sessions.

Results

95 patients were seen over two weeks. In the over 65 s, average time to be seen was 50 minutes quicker than the ED team over the same period, with reduced admission rate (25.7% vs 46.5%). The wait between decision to admit and departure was shortened by 119 minutes. Overall, this led to patients spending on average 133 minutes less in the ED. 64 patients were discharged, of which 44 had community follow-up (including 37.5% of 64 referred to acute elderly clinic and 25% to rapid response). 47 medications were stopped across 25 patients.

Conclusion

The pilot shows that introduction of an early comprehensive geriatric assessment in the ED can lead to patients being seen sooner, with more timely decisions over their care and reduction in hospital admissions. It allowed for greater provision of acute clinics and community services as well as prompt medication review and real time medication changes.
85 Improving Rates of Medication Prescription on Admission by the Clerking Doctor in Patients with Neck of Femur Fractures
Authors: Ang R J , Haye B , Noden S , Al-Saffar B Y
Published: March 2021

Introduction

Ensuring correct medications are prescribed for all patients admitted with neck of femur fractures is essential for presurgical optimisation, analgesia and perioperative care. This quality improvement project examines patients over the age of 65 who were managed following the orthogeriatric pathway for all neck of femur fractures at Queen Elizabeth Hospital, Woolwich. Guidelines exist that include a list of medications that should be prescribed for all of such patients on admission, including VTE prophylaxis, analgesia, antiemetics, laxatives, IV fluids and preload. The aim is to improve the rate of following this guidance on prescription by clerking doctors on admission.

Method

Data was collected retrospectively for all patients admitted to Queen Elizabeth Hospital between 03.12.19–15.01.20 with a neck of femur fracture. Interventions were then introduced to improve medication prescriptions and took place at the start of February 2020. This involved tutorial sessions and raising awareness through posters. Data collection for cycle 1 following interventions took place from 03.02.20–14.03.20 and can be compared with the original baseline data set.

Results

Data was collected from 34 patients for the baseline population and 28 patients in Cycle 1. Baseline data suggests that certain medications, such as preload and TEDs stockings were often missed by the admissions team, with only 8.82% of patients receiving 9 pm preload, 17.6% receiving 6 am preload and 38.2% prescribed TED stockings. Following interventions, medication prescriptions by the clerking doctors improved in all parameters, with significant improvements seen with VTE prophylaxis.

Conclusion

Induction sessions and accessible guidelines are essential to ensure guidelines are followed and patients receive correct medications on admission. Improving medication prescriptions is vital for medical optimisation prior to surgery and to lower rates of perioperative complications. Clerking doctors responsible for this task should receive correct training and support to ensure this is done correctly.
86 Reducing Inappropriate Readmissions From A Community Hospital—A Quality Improvement Project
Authors: Ronan D , Meadows L , Latcham N , Melrose R
Published: March 2021

Introduction

Quality person-centred care in those approaching the end of life includes consideration and anticipation of their preferred place of death and ceiling of care (CoC). This QI project to reduce inappropriate readmissions was prompted following the transfer of a palliative patient to the acute trust from a community hospital.

Method

Data was collected from the electronic patient record (EPR) at weekly intervals over a six month period, July to December. Electronic documentation of CoC from 507 records from a 24 bed community hospital was reviewed. Data collected included patient age, sex and whether a CoC decision entry had been made on the EPR during the community hospital inpatient stay. The appropriateness of readmissions over the same period was also analy sed. A weekly consultant geriatrician ward round was introduced focusing on advanced care planning with explicit decision making regarding preferred place of care.

Results

There were a total of 16 readmissions during the study period. 3 of these were deemed “inappropriate” following EPR review occurring in August, September and October. Subsequent review of electronic CoC July to October inclusive demonstrated a median completion rate of 20.5%. Following intervention there were no further inappropriate readmissions and the median CoC completion rate was 85%. Qualitatively, the consultant geriatrician managing the community hospital felt there had been a cultural shift where staff felt more comfortable managing complex palliative care.

Conclusions

Introduction of a weekly Consultant Geriatrician ward round in the community setting has led to a sustained improvement in CoC decision-making and documentation. As a result of this there have been no further inappropriate readmissions to the acute trust. This reflects the national guidance in patient centred palliative care. Further work including robust, qualitative assessment of staff attitude towards palliative care is needed to emulate this work at other local community hospitals.
88 Improving Clinical Effectiveness At Identifying Patients Requiring Advanced Care Plans
Authors: Nemchand P , Hassan D , Steel A
Published: March 2021

Our project was conducted in a district general hospital across five acute geriatric wards. Our team included consultants, registrars, and ward matrons. The project focused on improvement of care for geriatric inpatients, with moderate to severe frailty. Advanced care planning (ACP) columns are displayed on white boards. They indicate whether ACPs are required/initiated for each patient. When previously utilised, ACPs were initiated for 78% of appropriate patients [1]. Following a change in staff and reduction in awareness/education, the ACP column use reduced with fewer ACPs established.

Our goals were to ensure completion of the ACP column, encourage junior doctor/nurse involvement and trigger a greater number of appropriate ACPs initiated Improvement in ACP practice was addressed by daily board round review of appropriate patients for ACP, increasing awareness of ACP triggers and education around discussion content. Interventions consisted of: 1, a flow-chart adjacent to white boards prompting “Do not attempt resuscitation (DNAR)” and ACP processes. This signposted staff to information on ACP triggers and “how to start a conversation”. 2 Involving registrar “champions” on each ward. We explained our intervention to all team members to encourage engagement.

Data from the ACP columns were audited prior to intervention, 2 weeks and 6 weeks after intervention. There was a 54% increase in ACP documentation after 6 weeks across the wards.

The improvement in the use of the ACP column correlated with a greater number of ACPs initiated. This facilitated an increase in consideration of patient wishes towards the end of life. Increasing use of a daily ACP prompts on board rounds triggers an increase in ACP implementation for appropriate patients. Sustainability was achieved by recruitment of ward “ACP champions”. Junior doctors/matrons were more empowered to discuss ACPs. Results were presented at departmental teaching to reinforce the positive impact of the intervention.
91 Mrs Bad Bones: Impact of COVID-19 on Secondary Prevention of Fragility Fractures
Authors: Stephens A , Rudd H , Stephens E , Ward J
Published: March 2021

Introduction

Management of osteoporosis is an important consideration for neck of femur fracture patients due to the morbidity and mortality it poses, and the significant financial burden to the NHS. Orthogeriatric teams input is invaluable in coordinating secondary fragility fracture prevention. The COVID-19 pandemic resulted in the rapid restructuring of healthcare teams and led to the redeployment of the orthogeriatricians to assist with the influx of medically unwell patients. This study explored the impact COVID-19 had on secondary fragility fracture prevention.

Method

A retrospective audit looking at the prescription of vitamin D/calcium supplements, bone-sparing medications, and DEXA scan requests in consecutive neck of femur fracture patients admitted to a trauma and orthopaedic unit pre- and post- UK lockdown in response to the pandemic. A re-audit was conducted following the implementation of our new mnemonic, “MRS BAD BONES”: Medication Review Rheumatology/Renal Advice Smoking Cessation Blood tests Alcohol limits DEXA scan Bone-sparing medications Orthogeriatric review Nutrition Exercise Supplements.

Results

Data for 50 patients was available in each phase. The orthogeriatric team reviewed 88% of patients pre-lockdown falling to 0% due to redeployment, before recovering to 38% in the post-intervention period. Upon lockdown there was a significant drop in the prescription of vitamin D/calcium supplements from 81.6% to 58.0% (p = 0.0156); of bone-sparing medications from 60.7% to 18.2% (p = 0.0037), and DEXA scan requests from 40.1% to 3.6% (p = 0.0027). Following the implementation of our mnemonic, there was a significant increase in the prescription of vitamin D/calcium supplements to 85.7% (p = 0.0034), bone-sparing medications to 72.4% (p = 0.0002) and DEXA scan requests to 60% (p < 0.0001).

Conclusion

COVID-19 had a major impact on the secondary prevention of fragility fractures in this population. The “MRS BAD BONES” mnemonic significantly improved the management and could be considered for use in a wider setting.
97 Prescribing of Hypnosedatives in Seniors in Ambulatory Care in the Czech Republic: Inomed and Euroageism Project Findings
Authors: Antonenko O , Puldová K , Halačová M , Grešáková S , Brkic J , Fialová D
Published: March 2021

Introduction

Among psychotropic drugs, particularly hypnotics are often used by ambulatory seniors due to high prevalence of insomnia in higher age. This study focused on describing the prevalence of insomnia, prevalence of hypnosedative drug use and inappropriate patterns of their prescribing (nongeriatric doses, nongeriatric lenght of therapy) in ambulatory seniors in the Czech Republic.

Methods

There were 563 ambulatory geriatric patients (≥65 years) included in the study, from 4 geriatric ambulances (regionally different sites) in the Czech Republic. All patients have been assessed using comprehensive geriatric assessment (CGA) using the EUROAGEISM H2020 study protocols. Prevalences of insomnia, hypnosedative drug use and use of drugs that may exacerbate insomnias were documented by descriptive statistics, as well as the prevalence of potentially inappropriate medications in older patients (PIMs, selectively for hypnosedatives, defined by 2019 Beers criteria and 2015 EU(7)-PIM list).

Results

30.6% (N = 172) of ambulatory seniors suffered from insomnias and the majority of patients were treated pharmacologically (24.0%), nonpharmacologic procedures were used rarely (0.5%). Hypnosedatives in the evening or at night (e/n) were mostly prescribed in the age group of patients 84–94 years (42.8%) and most often these were Z-drugs (8.2%), benzodiazepines (BZDs, 7.6%) and from „off-label “hypnotics antipsychotics (17.8%,!17% of users 6 months) and sedative antidepressants (9.2%). In nongeriatric doses and nongeriatric duration of therapy (>4 weeks) there were most often prescribed Z-drugs (6.0% and 2,7%, respectively) and BZDs (2,7% and 11%).

Conclusion

In ambulatory Czech seniors we documented that one third suffered from insomnias and minimally were applied nonpharmacological treatment strategies. From nongeriatric procedures in hypnosetive drug use were most often described long-term use of antipsychotics e/n, non-geriatric dosing of Z-drugs and long-term use of BZDs e/n. Supported by: InoMed project (reg. No: CZ.02.1.01/0.0/0.0/18_069/0010046, 2019–2022), EUROAGEISM H2020-MCSF-ITN-764632 project, PROGRESS Q42 Faculty of Pharmacy, Charles University, SVV 260417.
100 Frailty Hot Clinics: Rapid Cga and Speciality Diagnostics Reduces Rates of Hospitalisation and Re-Attendance
Authors: Lim H J , Robson R , Alexander N , Cunningham R , Encisa D , Jhurry R , Owusu D , Remolan A
Published: March 2021

Introduction

Acute hospitalisation is associated with an increased risk of progressive frailty, morbidity and subsequent institutionalisation. North Middlesex University Hospital is an Acute District General Hospital with over 550 attendances to A&E per day. Comprehensive Geriatric Assessment (CGA) is the gold standard approach for a holistic multi-disciplinary assessment (MDT) of frail patients. A rapid access daily hot clinic service for frail patients opened using quality improvement (QI) methodology to deliver rapid CGA focusing on admission avoidance and early supported discharge.

Method

4 PDSA cycles were conducted. A process map identifying key moments in patient care was derived from time studies of the first 10 patients’ journeys. Patients were triaged through the Geriatrician “hotphone” for acute admissions into the Hot Clinic. Dedicated clinic and waiting rooms were placed on the acute frailty unit (Amber) staffed by a dedicated Consultant Geriatrician and Health Care Support Worker working with the Frailty Ward Clerk, Frailty Specialist Nurse, Therapies, specialities in-reach and same-day diagnostics. A shared clerking proforma and subsequent CGA Discharge Summary were completed and emailed to the referrer the same day. Qualitative and Quantitative feedback was gained from referrers, patients and relatives through a structured questionnaire. Metrics were gathered including rate of admissions, re-attendance and use of enhanced community services.

Results

From the first 48 Hot Clinic patients, there was a low 30-day re-attendance rate (17%—for unrelated reasons), low 30-day re-admission rates (4%) and low Did Not Attend rate (6%) for new referrals and high satisfaction scores for recommending the service (9-10/10) from patients, relatives and referrers.

Conclusions

Early rapid MDT can reduce re-attendances and re-admissions to hospital in frail patients. A streamlined patient journey can be delivered by frailty-trained staff and in a suitable environment. QI Methodology enables a structured measurable approach to development of the Acute Frailty Pathway.
101 Avoiding Burnout of the Care Home Workforce During the COVID-19 Pandemic and Beyond: Sharing National Learning and Local Initiatives
Authors: Johnston L , Malcolm C , Rambabu L , Hockley J , Shenkin S D
Published: March 2021

Introduction

COVID-19 in care homes has heightened the risk of staff burnout, undermining already problematic staff retention and low morale. There has been an associated proliferation of resources and online initiatives to support frontline workers, however, few of these are directly targeted at the care home workforce. Care home workers are highly skilled in caring for people with complex needs, but have very variable levels of formal training, and just over half of care homes in Scotland include registered nurses. This project will rapidly collate existing resources and identify, direct from care home workers, their best practice, initiatives, and resources used to support resilience and retention during this pandemic and moving forward.

Methods

1) Rapid review of care home specific evidence and resources (including published research and social media); 2) Online survey of Enabling Research in Care Homes (ENRICH) members across Scotland (n = 55); 3) Case studies within six care homes to identify what is working well and what is not in terms of promoting resilience and emotional support.

Results

The rapid review has identified a wide range of resources directed at supporting staff working in care homes; the survey and case studies will provide data on the key learning and resources that have supported staff, and outline the challenges identified. There are many resources available but staff do not access these. The role of the care home manager is key.

Key conclusions

This comprehensive review of resources and initiatives will make a valuable contribution to policy and practice designed to reduce burnout and foster retention not just in care homes but more widely across health and social care.
103 Periodontal Health and Sarcopenia: Cross-Sectional Evidence From A Cohort of 2040 Twin Volunteers
Authors: Zazzara M B , Wells P M , Bowyer R C E , Lochlainn M N , Thompson E J , Penfold R S , Steves C J
Published: March 2021

Introduction

Periodontitis is a chronic inflammatory disease affecting the periodontium, ultimately leading to looseness and/or loss of teeth. Sarcopenia refers to age-related reduction in muscle mass and strength. Similar to periodontitis, chronic low-grade inflammation is thought to play a key role in its development. In addition, both increase in prevalence with advancing age. Despite known associations with other diseases involving a dysregulated inflammatory response, for example rheumatoid arthritis,, the relationship between periodontitis and sarcopenia, and whether they could be driven by similar processes, remains uncertain. The aim of this study was to explore the association between periodontitis and sarcopenia.

Methods

Observational study of 2040 adult volunteers [age 67.18 (12.17)] enrolled in the TwinsUK cohort study. Presence of tooth mobility and number of teeth lost were used to assess periodontal health. A binary variable was created to define periodontitis. Measurements of muscle strength, muscle quality/quantity and physical performance were used to assess sarcopenia. A categorical variable was created according to the European Working Group on Sarcopenia in Older People (EWGSOP2) consensus, to define sarcopenia (1: probable; 2: positive; 3: severe). Generalised linear mixed model analysis used on complete cases and age-matched (n = 1,288) samples to ascertain associations between periodontitis and sarcopenia.

Results

No significant association was found between periodontitis and sarcopenia in both the complete cases analysis and age-matched analysis. Results were consistent when analysis was adjusted for potential confounders including body mass index, frailty index, Mini Mental State Examination smoking, nutritional status and educational level.

Conclusions

This study found no significant association between periodontitis and sarcopenia in a cohort of 2040 adults. Although both periodontitis and sarcopenia have been linked to a dysregulated immune response and demonstrate an increase in prevalence with increasing age, our work is inconclusive due to the plethora of possible aetiopathogenetic pathways.
108 A Multidisciplinary Team Initiative to End PJ Paralysis Was Successful in Achieving Cultural Change on An Acute Geriatric Ward
Authors: Butler J , Welford T
Published: March 2021

Introduction

Prolonged bedrest amongst the elderly causes deconditioning leading to; increased hospital length of stay, additional social costs and decreased quality of life. An audit on an acute geriatric ward in November 2018, found that over a third of patients medically fit (PMF) to sit out remained in bed all day. Therefore, a service development initiative was undertaken, addressing the misconception that keeping elderly patients in bed is safe, when in fact, unintentional harm results.

Method

In a root cause analysis, four main reasons for bedrest were identified: risk aversion, unknown function, widespread “bed is safe” culture and lack of equipment. The project tasked getting PMF out of bed each day and was audited daily from November 2018 to present, involving all members of the multi-disciplinary team (MDT) and using a “plan, do, study, act” approach.

Results

Initially, the project showed an increase in percentage of PMF sitting out each day, but this subsequently decreased with winter pressures. However, for a whole year (February 2019–February 2020) a sustained and significant improvement was achieved (64.3%–89.7%). The pre-COVID19 period (February–March 2020) saw fluctuations in PMF sitting out. Data collection halted during the COVID19 peak, although observationally most patients remained in bed. Auditing resumed from June 2020 (COVID19 recovery phase) which showed a steady increase in PMF out of bed, with recent figures surpassing pre-COVID19 levels (97.8%).

Conclusion

Cultural change takes time to embed and needs persistent reviewing by a dedicated and engaged MDT. Improvements were made through more accessible doctor’s advice, better MDT education and communication, daily feedback of data and sourcing additional equipment. Disruption to working patterns over the COVID19 period made this unachievable and the project lost impetus. In the COVID19 recovery phase, the specialized MDT reformed and worked successfully to restore the cultural change as evidenced by audited data.
121 Mediating Factors Between Caregiver Burden and Quality of Life in Caregivers of Older Patients with Newly Diagnosed Lung Cancer
Authors: Zhu S , Yang C , Li J , Mei W
Published: March 2021

Introduction

Family caregivers of older patients with newly diagnosed lung cancer become responsible for patients’ care, usually without preparation or training in provision of care. Their efforts of care generate caregiving burden, which could deteriorate their quality of life and affect the prognosis of patients. The aims of this study were to examine associations between caregiver burden and quality of life, coping, social support for family caregivers, and to investigate whether coping and social support mediate associations between family caregiver burden and their quality of life.

Methods

A cross-sectional study was performed at two thoracic surgery wards in one tertiary hospital in Changsha, China from November 2019 to May 2020. This study involved 224 family caregivers of patients aged over 50 years and newly diagnosed with lung cancer. Caregivers-reported outcomes were measured by Zarit caregiver burden interview, simplified coping style questionnaire, social support rating scale, and quality of life family version. Structural equation modeling (SEM) was used to test the hypothesized mediation model.

Results

SEM indicated a good fit for the mediation model, which explained 49.7% of the variance of quality of life. Higher level of caregivers’ burden was negatively associated with quality of life (r = 0.183, P = 0.042). Coping partially mediated the effect of caregiver burden on quality of life (indirect effect −0.389, P = 0.000). Social support did not mediate the relationship between caregiver burden and quality of life (indirect effect −0.023, P = 0.087).

Conclusions

Caregivers’ burden of patients with newly diagnosed lung cancer is correlated to quality of life which is partially mediated by coping. Early intervention providing caregivers with positive coping strategies may improve their quality of life.
124 Perceived Quality of End-Of-Life Communication Provided by Healthcare Professionals Among Frail Older Chinese Patients
Authors: Leung D Y P , Wan Z , Chan H Y L , Chiu P K C , Lo R S K , Tang F W K
Published: March 2021

Introduction

Better communications among the patient, their family, and healthcare providers can enable a shared understanding on patient’s end-of-life (EOL) care preferences. Discussion about death-related issue however has been thought to be taboo among Chinese people. This study aims to explore perceived quality of EOL communication provided by healthcare professionals (HCPs) among frail older Chinese patients.

Method

Frail older patients were recruited from a medical ward of a public hospital for a randomized controlled trial of the effectiveness of a nurse-led advance care planning. Participants completed a baseline questionnaire including the 7-item Quality of Communication (QOC) Questionnaire which measures perceived quality of EOL communication provided by HCPs (0 “The worst or none happened” to 10 “The best”). Bivariate analyses examined associated factors of QOC.

Results

Between December 2018 and January 2020, 105 participants were recruited and have completed the QOC. Their mean age was 80 years old (SD = 7.1), and 74% (n = 78) reported had received some formal education. A total of 95 participants (91%) responded “0” to all the 7 items in QOC (poor QOC group). For individual QOC item, all participants scored “0” in 4 items, 99 scored “0” in Item 1 “Talking about details if you got sicker”, 104 scored “0” in Item 2 “Talking about how long you might have to live”, and 101 scored “0” in Item 7 “Respecting your spiritual or religious beliefs”. Participants with “0” score in QOC reported a significant lower mean level in certainty regarding decision-making in EOL preferences (1.2 ± 1.6 vs. 2.3 ± 1.8, p = 0.039).

Conclusion

Occurrence of talking about EOL care with frail older Chinese patients by HCPs was rare, and the quality of EOL communication associated with decision-making certainty regarding EOL preferences. Training of initiation of EOL discussions and improve communication skills for HCPs is essential. Funding: RGC, HKSAR, China (PolyU14162617H).
125 A Case of Mistaken Identity: An Obsolete Anti-Reflux Device in An Older Patient with Variable Gastrointestinal Symptoms
Authors: Squires C , Porter R , Ward B
Published: March 2021

Background

A frail 93-year-old lady presented with delirium and hypoxia, on a background of heart failure, constipation, cerebrovascular disease, and osteoporosis. A CTPA on admission revealed an unusual appearance of the left hypochondrium, leading to subsequent CT abdomen. This unexpectedly reported the presence of a gastric band. We therefore considered a possible misidentification as this procedure seemed unlikely in someone of her age. Her GP records revealed that she underwent surgical insertion of an Angelchik prosthesis in 1984. It transpired that our patient had experienced several longstanding symptoms, including reflux, bloating and constipation, which have all been observed in patients with Angelchik prostheses in situ.

Discussion

The Angelchik prosthesis is an anti-reflux device for patients with chronic reflux disease with or without hiatus hernia, introduced in 1979. It comprised of an elastomer shell ring filled with silicone gel, that was sited at the lower oesophagus and secured with DACRON tapes. It was initially lauded for its replicable insertion technique and promising early results with around 30,000 being inserted in mainly British and American Hospitals. However, over time it became apparent that a significant proportion of patients reported ongoing gastrointestinal symptoms due to device failure.

Serious complications such as gastric perforations were also recognised. Surgical removal was noted to be technically complex, providing further challenges. The Angelchik prosthesis therefore fell from favour after a period of use of only fifteen years, and is now rarely encountered. We discovered that our patient had experienced multiple long-standing gastrointestinal complaints potentially linked to her prosthesis, though this association had not previously been considered. Whilst her frailty meant that removal would not be pragmatic, it is uncertain if this could have been a possible consideration in the past. This device is relevant to geriatricians as many recipients are now elderly, and may report ongoing symptoms.
130 Improving Documentation of Bowel Movement on Geriatric Wards
Authors: Noar A , Parkin J , Hallam R , Wijekoon T , Walker C , Khan H , Tsui J , Chin K , Chakravorty M , Zalynda R
Published: March 2021

Introduction

Constipation is a widely prevalent issue in older adults that may result in complications such as urinary retention, delirium and bowel obstruction. Previous studies have indicated that while stool charts are well completed by nursing staff, they are infrequently monitored by doctors. This project aimed to improve the documentation of bowel movement by doctors on ward rounds to 85%, by the end of a 3-month period.

Methods

Formulation of the project was achieved using group work and a fishbone diagram which focussed on how doctors can improve on documenting bowel movements. Baseline data were collected from inpatient notes on weekdays over a three-week period on a geriatric ward in Northern General Hospital, Sheffield. Interventions of posters and stickers of the poo emoji were placed on walls and in inpatient notes respectively as a reminder. Post-intervention data were collected on weekdays over two weeks, and then repeated a month later to assess for a sustained change.

Results

The data on bowel activity documentation were collected from 28 patients. The baseline data showed that bowel activity was monitored daily on the ward 56.25% of the time. There was a significant increase in documentation of 85.75% following the interventions. The sustainability study showed that bowel activity was documented on the ward 59.09% of the time.

Conclusions

This study shows how a strong effect on behavioural change can be accomplished through simple interventions such as stickers and posters. As most wards currently still use paper notes, this is a generalisable model that other wards can trial. However, this study also shows the difficulty in maintaining behavioural change over extended periods of time. Further PDSA cycles should examine the reasons behind the difficulty sustaining the change and implement new changes that aim to overcome them.
131 Developing An Integrated Comprehensive Geriatric Unit
Authors: Emery R , Chan C Sin , Farnsworth M
Published: March 2021

Introduction

Surrey Downs Health and Care (SDHC) is an innovative partnership consisting of the acute trust, community provider, three local GP federations and local authority. Together they deliver integrated health and care services for the Surrey Downs population. In April 2019, SDHC formally took over the management of an acute escalation ward at Epsom General Hospital. The aim was to redesign the model of care to offer a more integrated approach towards the management of patients with frailty.

Method

A change in leadership with interface frailty consultants developing an integrated multidisciplinary team (MDT) with reassignment of community staff. All members of the MDT had an equal voice and this helped develop the one team ethos. There were many developments along the way, but key changes included the agreement that a patients’ time is the most valuable currency and that we should be changing conversations from “what is the matter with you?” to “what matters most to you?”

Results

1. A 100% increase in average daily discharges 2. An increase to 70% being discharged to their own home, versus 20% previously 3. A reduction from an average length of stay of 40 days to 13 days compared to the same time last year 4. Reduced 30-day readmissions at 15% versus previous average of 25%.

Conclusion

By blurring boundaries between the acute and community, allowed a frictionless pathway for patients. This has led to improvement in patient care and outcomes for the patient and system as a whole.