bluuebunny/crossref_metadata_2025 huggingface dataset:
25 Sarcopenia, Long-Term Conditions, and Multimorbidity From Mid-Life to Later Life: Findings From 499,046 UK Biobank Participants
Authors: Dodds R M , Granic A , Robinson S M , Sayer A A
Published: March 2021

Introduction

Sarcopenia, the loss of muscle strength and mass, predicts adverse outcomes and becomes common with age. There is recognition that sarcopenia may occur at younger ages in those with long-term conditions (LTCs) as well as those with multimorbidity (the presence of two or more LTCs), but their relationships have been little explored. Our aims were to describe the prevalence of sarcopenia in UK Biobank, a large sample of men and women aged 40–70 years, and to explore relationships with different categories of LTCs and multimorbidity.

Methods

We used data from 499,046 participants in the baseline of UK Biobank. Our main outcome was probable sarcopenia based on maximum grip strength below sex-specific cut-points. Participants’ LTCs were recorded during an interview and categorised against a hierarchy. We used logistic regression to examine the independent associations between each category of LTCs and probable sarcopenia, including adjustment for age, sex, and body mass index. We also examined the association with multimorbidity.

Results

Probable sarcopenia had an overall prevalence of 5.3% and increased with age. The categories with the strongest associations with probable sarcopenia were musculoskeletal/trauma (OR 2.17 [95% CI: 2.11, 2.23]), endocrine/diabetes (OR 1.49 [95% CI: 1.45, 1.55]), and neurological/psychiatric (OR 1.39 [95% CI: 1.34, 1.43]) LTCs. Almost half of the sample (44.5%) had multimorbidity and they were at nearly twice the odds of probable sarcopenia (OR 1.96 [95% CI: 1.91, 2.02]) compared to those without.

Conclusions

We have shown an overall prevalence of 5.3% of probable sarcopenia at ages 40–70 in UK Biobank. The risk of probable sarcopenia was higher in those with some categories of LTCs, suggesting that these groups may stand to benefit from assessment of sarcopenia, during mid-life as well as old age.
29 Predicting Unplanned Readmission and Death After Hospital Discharge: How Do Frailty Tools Compare to Electronic Health Record Frailty Markers?
Authors: Anand A , Tew Y Yong , Chan J Hao , Keeling P , Shenkin S D , MacLullich A , Mills N , Denvir M A
Published: March 2021

Introduction

Numerous frailty tools and definitions have been described. Amongst hospitalised patients, the validity of face-to-face instruments may be confounded by acute illness. However, patient assessment after recovery at the point of hospital discharge, or recognition of electronic health record (EHR) frailty markers, may overcome this issuep.

Methods

In a consented, prospective observational cohort study, we recruited patients ≥70 years old within 24 hours of expected discharge from the cardiology ward of the Royal Infirmary of Edinburgh. Three established frailty instruments were tested: the Fried phenotype, Short Physical Performance Battery and nurse-administered Clinical Frailty Scale (CFS). An unweighted 32-item EHR score was generated using frailty markers (e.g. falls risk, continence, cognition) recorded within mandated admission documentation. Comorbidity was assessed by count of chronic health conditions. Outcomes were a 90-day composite of unplanned readmission or death and 12-month mortality. Adjusted Cox modelling determined the hazard ratio (HR) per standard deviation increase in each frailty score.

Results

186 patients (mean age 79 ± 6 years, 64% male) were included, of whom 55 (30%) had a 90-day composite outcome, and 21 (11%) died within 12 months. All four frailty tools were moderately correlated with age and comorbidity (Pearson’s r 0.21 to 0.43, all p < 0.05). The Fried phenotype (HR 1.47, 95% CI 1.18–1.81), CFS (HR 1.24, 95% CI 1.01–1.51) and EHR score (HR 1.26, 95% CI 1.03–1.55) independently predicted 90-day readmission or death, after adjustment for age, sex and comorbidity. All frailty instruments were independent predictors of 12-month mortality, with age, sex and comorbidity losing predictive power (p > 0.05) once frailty was included in modelling.

Conclusions

At hospital discharge, the Fried phenotype and CFS added to age and comorbidity in risk prediction for future unplanned readmission or death. EHR frailty markers appeared comparable to face-to-face assessment. An automated trigger for high-risk patients using routine EHR data merits prospective evaluation.
33 Diagnostic Test Accuracy of the 4AT for Delirium Detection: Systematic Review and Meta-Analysis
Authors: Tieges Z , MacLullich A M J , Anand A , Cassaroni M , O'Connor M , Ryan D , Saller T , Arora R , Chang Y , Agarwal K , Taffet G , Quinn T , Shenkin S , Galvin R
Published: March 2021

Introduction

Detection of delirium in hospitalised older adults is recommended in national and international guidelines. The 4 ‘A’s Test (4AT; www.the4AT.com) is a short (<2 min) instrument for delirium detection that is used internationally as a standard tool in clinical practice. We performed a systematic review and meta-analysis of diagnostic test accuracy of the 4AT for delirium detection.

Methods

We searched the following electronic databases through Ovid: MEDLINE, Embase, and PsycINFO. Additional databases were searched: CINAHL (EBSCOhost), clinicaltrials.gov and Cochrane Central Register of Controlled Trials from 2011 (4AT publication) until 21 December 2019. Inclusion criteria: older adults (≥65) across any setting of care except critical care; validation study of the 4AT against a delirium reference standard (standard diagnostic criteria or validated tool). Two reviewers independently screened abstracts and papers and performed the data extraction. Pooled estimates of sensitivity and specificity were generated from a bivariate random effects model.

Results

17 studies (n = 3,701 observations) were included. Various settings including acute medicine, surgery, stroke wards and the emergency department were represented. The overall prevalence of delirium was 24.2% (95% CI 17.8–32.1%; range 10.5–61.9%). The pooled sensitivity was 0.88 (95% CI 0.80–0.93) and the pooled specificity was 0.88 (95% CI 0.82–0.92). The methodological quality of studies was mostly good.

Conclusions

The 4AT is now supported by a substantial evidence base comparable to other well-studied tools such as the Confusion Assessment Method (CAM). The strong pooled sensitivity and specificity findings for the 4AT in this meta-analysis along with its brevity and lack of need for specific training provide support for its use as an effective assessment tool for delirium.
35 Social Contact Mode and 15-Year Episodic Memory Trajectories in Older Adults with and Without Hearing Loss: the Elsa Study
Authors: Rafnsson S , Maharani A , Tampubolon G
Published: March 2021

Introduction

Frequent social contact benefits cognition in later life although evidence is lacking on the potential importance of the modes chosen by older adults for interacting with others in their social network.

Method

11,513 participants in the English Longitudinal Study of Ageing (ELSA) provided baseline information on hearing status and social contact mode and frequency of use. Multilevel growth curve models compared episodic memory (immediate and delayed recall) at baseline and long-term in participants who interacted frequently (offline only or offline and online combined), compared to infrequently, with others in their social network.

Results

Frequent offline (β = 0.29; p < 0.05) and combined offline and online (β = 0.76; p < 0.001) social interactions predicted better episodic memory after adjustment for multiple confounding factors. We observed positive long-term influences of combined offline and online interactions on memory in participants without hearing loss (β = 0.48, p = 0.001) but not of strictly offline interactions (β = 0.00, p = 0.970). In those with impaired hearing, long-term memory was positively influenced by both modes of engagement (offline only: β = 0.93, p < 0.001; combined online and offline: β = 1.47, p < 0.001). Sensitivity analyses confirmed the robustness of these findings.

Conclusion

Supplementing conventional social interactions with online communication modes may help older adults, especially those living with hearing loss, sustain, and benefit cognitively from, personal relationships.
41 A New Ambulatory Frailty Pathway at Barnsley Hospital
Authors: Rycroft W , Madi B
Published: March 2021

Topic

At Barnsley Hospital we targeted an improvement in the care of frail patients. The first objective was to improve the patient journey by reducing the amount of time that frail patients spend in busy acute environments. The second objective was to deliver more effective Comprehensive Geriatric Assessment which is recognised as gold standard management (Ellis, G. BMJ 2011;343:d6553).

Intervention

A new frailty chaired area was opened in July 2018 with capacity to receive up to 6 patients per day from acute admission areas and aim for same day discharge.

We developed our own bespoke criteria to ensure that suitable ambulatory patients were identified to access this new pathway. This was called “FACT” Criteria- Frail, Ambulatory, Clinically stable, Time to call. Patients received an MDT model of care which was documented using a newly developed electronic tool called electronic Comprehensive Geriatric Assessment (eCGA).

Improvement

To evaluate the patient journey we measured the average time between the Acute Medical Unit (AMU) Post Take Ward Round (PTWR) and onward move. Comparison was made between the 2 month periods July—August and November—December 2018. This demonstrated that the average time reduced from 10.3 to 5.1 hours.

Between July 2018 and April 2019 a total of 689 patients were assessed in the frailty chaired area of which 60.8% were discharged from the hospital the same day.

Discussion

The patient journey for frail ambulatory patients now involves significantly less time on AMU awaiting onward move. Comprehensive Geriatric Assessment is delivered more effectively and documented electronically using eCGA. This tool promotes better information sharing and has a specific section for advance care planning.

This new pathway has a high same day discharge rate of 60.8% which reduces length of stay for our frail patients.
45 Quality Improvement Project on Delirium Care in Older Patients at Mid Yorkshire Hospitals NHS Trust (MYHT)
Authors: Mon H , Holt R
Published: March 2021

Background

To improve delirium care in older patients admitted to a large district general NHS Trust in the UK, a quality improvement project was conducted.

Introduction

The national NICE guidelines (CG103) and recent SIGN guidelines recommend delirium is diagnosed by a clinical assessment based on DSM criteria (e.g. CAM or 4AT) and managed by identifying and treating the causes alongside multicomponent interventions.

The results of MYHT’s 2018 delirium audit showed the use of CAM or 4AT was 32.5% and delirium care plan was 20%. A quality improvement project was developed and implemented for 6 weeks on a frailty admission unit.

Method

The quality improvement project introduced a delirium care checklist sticker for medical notes in cases of suspected delirium, brief education sessions for ward doctors regarding delirium care and use of the sticker and reminder emails, all implemented by the elderly medicine registrar. The target measures were completion of stickers, 4AT and delirium care plan. Data was collected by the registrar once a week for 6 weeks and entered into a run chart. Feedback was collected from staff on barriers to use.

Results

31 patients with suspected delirium has their notes reviewed. The sticker use gradually reduced from 57% of cases in week 1, to 0% in week 6. The 4ATwas completed in 57%, 50% and 100% of cases in the first 3 weeks, but dropped to 40%, 4.2% and 1.3% in the last 3 weeks. A delirium care plan was initiated in 42% and 37% of cases in the first two weeks but ended at 0% by week 6.

Barriers included a lack of education sessions from week 2 onwards due to registrar on call shifts. Also junior doctor changeover in week 3. Feedback indicated barriers were time taken to complete, and confusion over ownership of completing 4AT and care plan between medical and nursing teams.

Conclusion

Although a delirium care checklist sticker and brief education sessions can improve delirium care, sustained improvement requires ongoing education and addressing barriers to completion.

References

1. National Institute for Health and Care Excellence (2019) Delirium: prevention, diagnosis and management (NICE Guideline CG103). Available at: https://www.nice.org.uk/guidance/cg103 Accessed 21/09/2019].

2. Scottish Intercollegiate Guidelines Network (2019) risk reduction and management of delirium (SIGN Guideline 157). Available at https://www.sign.ac.uk/assets/sign157.pdf. Accessed 21/09/2019.
48 Do Exercise Programmes for Older People with Sarcopenia or Frailty Deliver An Evidence-Based Service? Findings From A UK Survey
Authors: Chawner M , De Biase S , Offord N J , Todd O , Clegg A , Sayer A A , Witham M D
Published: March 2021

Background

Awareness of sarcopenia and frailty is growing and both are known to be potentially reversible with effective resistance training. We aimed to establish whether existing exercise programmes offered to people with sarcopenia or frailty adhere to the known evidence base.

Methods

We conducted a national on-line survey of practitioners delivering exercise programmes to older people with sarcopenia or frailty. The link to the online survey was distributed through the British Geriatrics Society, Chartered Society of Physiotherapy Special Interest Group for Older People (AGILE), the NHS England Future Collaboration Platform “Supporting People Living with Frailty” forum and social media. Questions covered target population and aims of the exercise programme, type, duration and frequency of exercise, progress assessment and outcome measures. Descriptive analyses were conducted using SPSS v24.

Results

136 responses were received from respondents who worked for NHS Trusts, clinical commissioning groups, private practices, and third sector providers. 94% of respondents reported prescribing or delivering exercise programmes to people with sarcopenia or frailty. Most programmes (81/135 [60%]) were primarily designed to prevent or reduce falls. Resistance training was reported as the main focus of the programme in only 11/123 (9%); balance training was the main focus in 61/123 (50%) and functional exercise in 28/123 (23%). Exercise was offered once a week or less by 81/124 (65%) of respondents; the median number of sessions offered was 8.5 (IQR 6 to 12). Outcome measures suitable for assessing the effect of resistance training programmes were reported by fewer than half of respondents (hand grip: 13/119 [11%]; chair stands: 55/119 [46%], short physical performance battery: 4/119 [3%]).

Conclusions

Current exercise programmes offered to older people with sarcopenia or frailty lack the frequency, duration or specificity of exercise likely to improve outcomes for this group of patients.
139 What are the Barriers and Facilitators to Effective Advance Care Planning (ACP) in Residential Care Settings for Older People?
Authors: Chumbley K
Published: March 2021

Introduction

ACP is recommended for all people approaching the end of life but there is an inequality in access to ACP for care home residents. In North East Essex there has been an Electronic Palliative Care Coordination system (EPaCCS) in place for 6 years, currently without care home staff access capability. The aim of this study was to investigate ACP within care homes within this context.

Method

A qualitative study, with semi-structured interviews with fourteen senior care home staff from ten care homes across North East Essex. The interview transcripts underwent thematic analysis regarding facilitators and inhibitors to effective ACP.

Results

Four overarching themes were identified. These were relationships, communication, healthcare systems and attitudes. Care home staff considered ACP to be part of their role but perceived their work in this area to be separate from that performed by other health care professionals. The care home staff awareness of ACP done by other health care professionals was limited. Care home staff were aware of the EPaCCS, but only a minority perceived it to impact on residents care. All interviewees were keen to have access to the EPaCCS. Many of the facilitators and barriers to effective ACP in this locality are consistent with those found in prior literature. Having an EPaCCS within the area did not alleviate a perceived barrier of poor communication. Relationships between staff, residents, families and health care professionals remain the most common facilitators to ACP, with continuity of care from primary care, specialist palliative care and paperwork tools remaining important.

Conclusion

To overcome the inequity of access to ACP for residents in care homes interventions could be commissioned to address current barriers. These could include communication skills training, aligned primary care and community services as well as technological support for communication with family and access to EPaCCS.
143 Barriers and Facilitators of General Practice in the Care Home Setting- A Qualitative Study to Inform Training of GPS
Authors: Ruaux S , Chadborn N
Published: March 2021

Introduction

Care home (CH) residents receive varying quality and availability of healthcare. GPs are tasked with the responsibility of providing effective care to this growing demographic. The study aimed to gain an insight into the experiences of GPs carrying out CH work, in order to produce training recommendations.

Method

Two trainees, one trainer and twelve senior GPs were recruited informally through professional networks. Each completed a semi-structured interview about their work within CHs. Transcriptions were made and then analysed using thematic analysis.

Results

The two trainee participants had different experiences of CH work, but neither had received any specific training. The trainer GP acknowledged that multiple existing trainee competencies were relevant to CHs, but that inconsistencies in CH exposure were present and that specific training would be beneficial. The senior GP participants did not recall having received CH-specific training. Many factors contributed to the delivery of care within the CHs and made it distinct from the work within the GP surgery. Participants reported a variety of approaches to care, these related to different multidisciplinary teams, the involvement of CH staff, and the complex nature of the care of residents. Advance care planning was a beneficial approach used by some of the GPs that required particular attention and skills.

Conclusion

A tension was present between the care GPs wanted to provide and the complexities that inhibited them from doing so. The challenges relate to the need for multidisciplinary care teams to address complex needs of individual residents, and an acknowledgement of the importance of the relationship with the CH staff in supporting continuity of care. Overall, the complex nature of CH work, and the current inconsistencies in trainee’s exposure, justify the need for a new approach to provide all trainee GPs with experience of working within the CH setting.
144 Probable Delirium is A Presenting Symptom of COVID-19 in Frail, Older Adults: A Study of Hospitalised and Community-Based Cohorts
Authors: Penfold R S , Zazzara M B , Roberts A L , Lee K A , Dooley H , Sudre C H , Welch C , Bowyer R C E , Visconti A , Mangino M , Freidin M B , El-Sayed Moustafa J S , Small K , Murray B , Modat M , Wolf J , Ourselin S , Martin F C , Steves C J , Ni Lochlainn M
Published: March 2021

Introduction

COVID-19 exhibits a more severe disease course in older adults with frailty. Awareness of atypical presentations is critical to facilitate early disease identification. This study aimed to assess how frailty affects presenting symptoms of COVID-19 in older adults.

Methods

Observational study of two distinct cohorts: (i) Hospitalised patients aged 65 and over; unscheduled admission to a large London teaching hospital between March 1st, 2020-May 5th, 2020; COVID-19 confirmed by RT-PCR of nasopharyngeal swab (n = 322); (ii) Community-based adults aged 65 and over enrolled in the COVID Symptom Study mobile application between March 24th (application launch)-May 8th, 2020; self-report or report-by-proxy data; reported test-positive for COVID-19 (n = 535). Multivariable logistic regression analysis performed on age-matched samples of both cohorts to determine associations between frailty and symptoms of COVID-19 including delirium, fever and cough.

Results

Hospital cohort: there was a significantly higher prevalence of delirium amongst the frail sample, with no difference in fever or cough. Of those presenting with delirium, 10/53 (18.9%) presented with delirium as the only documented symptom. Community-based cohort: there was a significantly higher prevalence of probable delirium in the frail sample, and also of fatigue and shortness of breath. Of those reporting probable delirium, 28/84 (33%) did not report fever or cough.

Conclusions

This study demonstrates a higher prevalence of delirium as a presenting symptom of COVID-19 infection in older adults with frailty compared to their age-matched non-frail counterparts. Clinicians should suspect COVID-19 in frail older adults presenting with delirium. Early detection facilitates infection control measures to mitigate against catastrophic spread and preventable hospitalisations and deaths amongst this population. Our findings emphasise the need for systematic frailty assessment for all acutely ill older patients in both hospital and community settings, as well as systematic evaluation of any change in mental status.
154 The Feasibility of Assessing Sarcopenia Among Older People with Arm Fracture Using Different Criteria
Authors: Ibrahim K , Mullee M A , Yao G Lily , Zhu S , Baxter M , Tilley S , Russel C , Roberts H C
Published: March 2021

Introduction

Osteoporosis and sarcopenia often co-exist (osteo-sarcopenia) and both are associated with increased risk of falls and fractures. Early identification and treatment of sarcopenia among older people with fragility arm fractures could prevent further fractures. This study evaluated the feasibility of assessing sarcopenia in a fracture clinic.

Methods

People aged 65+ years with arm fracture attending fracture clinics in one acute trust were recruited. Sarcopenia was assessed using gait speed, grip strength with unfractured arm (hand dynamometer using appropriate cut off adjusted for age and gender), skeletal muscle mass index SMI (Bioimpedance BIA), SARC-F questionnaire, the European Working Group on Sarcopenia in Older People (EWGSOP) I and II criteria. The sensitivity and specificity of each measure was calculated against the EWGSOP II criteria as the standard reference.

Results

100 patients (Mean age 75 years±7.2; 80 female) were recruited. Sarcopenia was identified among 4% (EWGSOP I), 5% (SMI), 13% (EWGSOP II), 16% (gait speed test), 18% (SARC-F) and 39% (grip strength) and was more prevalent among men. SARC-F had the best sensitivity and specificity (100% and 96% respectively) when compared to the EWGSOP II criteria. Sensitivity and specificity for the remaining measures were respectively (100%, 71%) for grip strength, (75%, 94%) for gait speed, (25%, 97%) with SMI and (25%, 99%) for EWGSOP I. Time needed to complete the assessments was 1–2 minutes for gait speed, grip strength and SARC-F; five minutes for BIA test, and nine minutes when EWGSOP I and II criteria were applied. Data were complete for grip strength and SARC-F. Missing data was reported among 2% for gait speed, 8% for BIA test, 8% for EWGSOP II and 10% for EWGSOP I.

Conclusion

It was feasible to assess sarcopenia in fracture clinics and SARC-F was a quick, simple and sensitive tool suitable for routine use.
159 Antibiotic Omissions: A Missed Dose Means A Missed Chance to Save A Life! Is E-Prescribing the Answer?
Authors: Manzoor M , Atique A , Chowdhury R , Athavale N
Published: March 2021

Omissions and delay in antimicrobial therapy are common in acute hospitals with an untowrds impact on patient outcomes resulting in harm and prolong stay. We carried out a Quality Improvement Project (QIP) assessing 2 interventions in PDSA cycles to improve situation. This QIP was done in 3 stages and involved about 80 patients over 7 months. We collected data regarding antibiotic omissions on 3 random separate days which gave baseline omission rate. This was 8.5% and quite higher than the national average (5.3%). The reason for the omissions was not documented on the drug kardexes on most occasions. Initial intervention included staff education, verbally and through posters. Post intervention data was collected again on 3 separate days. This showed improvement and the omission rate fell from 8.5% to 5.6%. The percentage of omissions with no code written reduced from 56.25% to 18.18%. The second intervention included participation in EPMA (Electronic prescribing and medicines administration) pilot on the ward. Post EPMA, the omission rate reduced to 4.59%. All omissions had now a code written. The phenomenon of Antibiotic Omissions is an open challenge and its consequences are serious. We can conclude from our study that educational measures though effective are likely to be short-lived.Therefore, it can be asserted that Electronic prescribing is appropriate solution for antibiotic omissions and it also opens up new horizons for patient safety.
58 The Benefits of A Virtual Ward Model in the Management of Care of Elderly Patients Admitted with Decompensated Heart Failure
Authors: Reid P , Kandasamy V , Chambers B , Tomos L , Procter H , Pushpangadan M , Bulugahapitiya S
Published: March 2021

Introduction

Heart failure in elderly patients is associated with increasing rates of hospitalisation and readmission. The Care of Elderly department at Bradford Royal Infirmary has developed a virtual ward service to support patients at home on discharge from hospital. We wished to assess if patients admitted with heart failure and discharged under the virtual ward model had a reduced length of stay in hospital and if their readmission rate was altered, compared to patients not discharged under the virtual ward.

Method

A retrospective study of patients admitted under the Care of Elderly team with decompensated heart failure was undertaken. Patients admitted over 12 months were identified and assessed length of stay and readmission rates at 7 and 30 days post admission. There were no set criteria for discharge to the virtual ward, but patients were selected for virtual ward care based on; symptom burden, renal function and ongoing PT/OT support.

Results

Of the 358 patients identified in this study, 83 (23%) were discharged to the virtual ward (VW). On average patients spent 7 days (+/− 5.3) under the virtual ward service. Average length of hospital stay for VW patients was 2.3 days compared to 6.5 days for patients not discharged under the virtual ward (p < 0.0001). Of the patients discharged to the virtual ward, 8 (10%) were readmitted within 7 days and 23 (28%) were readmitted within 30 days, similar to readmission rates in patients not discharged under the virtual ward with 25 (11%) and 62 (27%) patients readmitted after 7 and 30 days respectively.

Conclusions
65 Comparison of Frax and Qfracture in Predicting Fragility Fractures in Patients Presenting with Falls
Authors: Brook S , Todorov G , Comninos A N
Published: March 2021

Introduction

Falls are a major risk factor for fragility fractures and patients should be appropriately assessed to reduce future fragility fracture risk. National guidelines provide recommendations on assessing fracture risk using calculators to guide therapy initiation. FRAX and QFracture are the two main calculators used, however they differ considerably in their inputs. The aim of this study was to compare the risk estimation and performance between these two frequently used calculators to help determine their appropriate utility.

Methods

Data from patients aged ≥70 years admitted with a fall to the Acute Medical Units at Charing Cross Hospital between 1st Dec 2018–31st March 2019 were retrospectively collected, covering all inputs required for the two risk calculators.

The 10-year major osteoporotic and hip fracture risks were calculated using FRAX and QFracture and compared. The one-year major osteoporotic and hip fracture risks from QFracture were assessed against actual one-year fracture rates.

Results

Conclusions

Risk calculators are effective tools to aid the decision of bone therapy initiation. Here we demonstrate that there is a strong correlation between the two commonly used calculators. However, in terms of absolute risk values there is a mean 8.9% difference with QFracture providing higher risks in this “fallers” group. As absolute treatment thresholds are frequently used to guide bone therapy initiation, opposing recommendations may result. Therefore, there is a need to further explore calculator performance and determine which would more accurately serve different patient groups.
71 Developing A Portfolio for Advanced Practitioners Working with Older People
Authors: MacDiarmid L
Published: March 2021

Introduction

Advanced Nurse Practitioners (ANP’s) have a professional responsibility to ensure that they maintain professional competence (Whiteing, N. in Hinchcliffe and Rogers Eds pp192–219, 2008).

The aim of the portfolio is to assist ANP’s in developing evidence demonstrating continued advanced level practice. At the time of the study, there was a dearth of evidence relating to competencies for qualified ANP’s, working with older people.

The aim was to move away from the traditional confines of “nurse does this, doctor does this”, and to embrace the concept of developing skills to meet the clinical demands of service provision for our older people.

Methods

Participatory action research methodology was adopted—using the Review, Plan and act cycle (Edwards and Talbot, p63 1999; Holloway & Wheeler p155–156, 1996).

Review

A literature search and review of competencies relating to advanced practice and older people was undertaken.

Plan

A portfolio of knowledge and skills was collated utilising the information from the review. A matrix was created incorporating four Pillars of Advanced Practice (SGHD 2008), the Nursing and Midwifery Code (NMC, 2015) and modified competencies for Joint Royal Colleges of Physicians Training Board Geriatric curriculum (JRCPTB), (2010, amended 2013 and 2015).

The portfolio was sent out to existing team members, and local Consultant Geriatricians based in the Acute Trust and local University for comment and amendments were made.

Act

The portfolio was used by staff as a trial and evaluated.

Written feedback was obtained through questionnaires.

Results

The portfolio was well evaluated by staff using it, including recommendations for improvement.

Portfolio has been shared at national groups and via social media and has been well received.

Conclusions

An Advanced Practice Portfolio of capabilities is being used, based on action research cycles, enhancing the level of care received by older people.
75 Community Dnacpr Forms: Opening A Can of Worms
Authors: Odone J , Schiff R
Published: March 2021

Background

There is no national guidance for the transfer of Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) decisions between care settings. This issue has been highlighted within our Integrated Care Trust. We reviewed our local process, to improve the transfer of DNACPR decisions between care settings.

Method

A third PDSA cycle was completed to evaluate intervention.

Intervention

Frequently asked questions were added to the reverse side of the DNACPR form to improve patient understanding. All patients discharged home were given this updated form during a pilot study. The impact of the intervention was analysed with a follow-up phone call (n = 30) and discussed at a staff focus group.

Results

No improvement in patient understanding was shown post-intervention, however the intervention was overwhelmingly supported by staff. 60% of patients reported receiving a DNACPR form on discharge and 12% recalled being informed that they would be discharged home with a form.

Conclusion

Further work is required on the DNACPR pathway across primary and secondary care. The next cycle will involve ensuring that the community form is highlighted in hospital discussions regarding DNACPR decisions.
78 A Quality Improvement Project on Oxygen Administration Within the Geriatrics COVID-19 Cohort Ward
Authors: Hickson L , Liu A K L , Bailey G , Bruce S , Kawafi K , Reid D , Gowda V
Published: March 2021

Introduction

Due to the COVID-19 pandemic, many medical and surgical wards were reassigned as COVID-19 cohort wards to accommodate the number of patients admitted with the virus. Nurses and healthcare assistants (HCAs) from various departments and backgrounds were redeployed to these areas. Within the geriatrics population, patients with severe COVID-19 often have high oxygen requirements and can rapidly deteriorate. Therefore, we conducted a quality improvement project within the geriatrics COVID-19 ward focused on improving patient safety by improving oxygen administration to patients. We also aimed to enhance the knowledge and confidence levels of nurses and HCAs in regards to oxygen administration.

Method

From April–July 2020, we compared the oxygen that was administered to COVID-19 patients against the oxygen therapy that was documented on observation charts. This included whether the correct type of device, flow rate and target oxygenation saturations were used. We carried out multiple Plan-Do-Study-Act (PDSA) cycles including a staff education session on oxygen administration, placed an oxygen guidelines poster on each patient’s bedside, administered a short quiz and distributed reminder lanyard cards. We also conducted a staff survey comparing knowledge and confidence on oxygen administration before and after an education session.

Results

Overall there has been an improvement in oxygen charting and administration after 4 PDSA cycles. There is 100% correct use of oxygen device and correct setting of oxygen flow rate after the 2nd and 3rd PDSA cycles. After the teaching session, all staff reported feeling more confident in oxygen management. Based on the audit data and quiz results, there was an improvement in knowledge of oxygen administration.

Conclusions

We have demonstrated that by using simple time-efficient and cost-effective interventions, improvements can be made in oxygen administration and subsequently patient safety. This has the potential to influence prognostic outcomes among the geriatrics population with COVID-19.
80 Improving Documentation of DNAR Decisions on the Acute Medical Take
Authors: Sweeney A , Bellenberg H , Butt H , Badat S , Epstein D
Published: March 2021

Introduction

The BMA, Resuscitation Council and Royal College of Nursing have set out clear guidelines on documentation of Resuscitation discussions and decisions.1 On the acute medical take documentation of these discussions and decisions can be unclear despite use of an electronic patient record (EPR). The aim of this audit was to improve documentation of Do Not Attempt Resuscitation (DNAR) decisions in EPR.

Methods

We listed patients admitted on the medical take over 1-week, looking at resuscitation status and the documentation of the DNAR decision. We then implemented a change to the format of the EPR treatment escalation plan (TEP) form. Prior to the change the DNAR form was behind the TEP form which had to be clicked on separately and was not mandatory to complete. After the intervention the DNAR decision was placed in a box on the front page of the TEP form to ensure that it was clear and accessible.

Results

Pre-intervention we reviewed 114 patients notes of which 94 were DNAR. Of these 94 only 17 (18%) had correctly documented DNAR decisions in EPR. Following the intervention we again looked at all admissions to the medical take over a 1-week period, out of 151 patients 75 were DNAR and of these 75 patients 29 had correctly documented DNAR forms. This shows an increase in the percentage of the DNAR decisions filled in from 18% to 39%.

Conclusion

The results show that although there has been an improvement in the number of DNAR decisions being documented there are still a large percentage of patients who do not have this correctly documented. We are designing further interventions to ensure that the DNAR documentation is marked as a mandatory part of the TEP form as well as educating around the importance of this documentation.
84 COVID-19 and Associations with Frailty and Multimorbidity: A Prospective Analysis of UK Biobank Participants
Authors: Woolford S J , D’Angelo S , Curtis E M , Parsons C M , Ward K A , Dennison E M , Patel H P , Cooper C , Harvey N C
Published: March 2021

Introduction

Frailty and multimorbidity have been suggested as risk factors for severe COVID-19 disease. We therefore investigated whether frailty and multimorbidity were associated with risk of hospitalisation with COVID-19 in the UK Biobank. Method 502,640 participants aged 40–69 years at baseline (54–79 years at COVID-19 testing) were recruited across UK 2006–10. A modified assessment of frailty using Fried’s classification was generated from baseline data. COVID-19 test results (England) were available 16/03/2020–01/06/2020, mostly taken in hospital settings. Logistic regression was used to discern associations between frailty, multimorbidity and COVID-19 diagnoses, adjusting for sex, age, BMI, ethnicity, education, smoking and number of comorbidity groupings, comparing COVID-19 positive, COVID-19 negative and non-tested groups.

Results

4,510 participants were tested for COVID-19 (positive = 1,326, negative = 3,184). 497,996 participants were not tested. Compared to the non-tested group, after adjustment, COVID-19 positive participants were more likely to be frail (OR = 1.4 [95%CI = 1.1, 1.8]), report slow walking speed (OR = 1.3 [1.1, 1.6]), report two or more falls in the past year (OR = 1.3 [1.0, 1.5]) and be multimorbid (≥4 comorbidity groupings vs 0–1: OR = 1.9 [1.5, 2.3]). However, similar strength of associations were apparent when comparing COVID-19 negative and non-tested groups. Furthermore, frailty and multimorbidity were not associated with COVID-19 diagnoses, when comparing COVID-19 positive and COVID-19 negative participants.

Conclusions

Frailty and multimorbidity do not appear to aid risk stratification, in terms of a positive versus negative results of COVID-19 testing. Investigation of the prognostic value of these markers for adverse clinical sequelae following COVID-19 disease is urgently needed.
89 Improving Pain Assessment and Management for Patients with Cognitive Impairment on the Care of the Older Person (COOP) Wards
Authors: Ryan K , Whitehead J , Lindenberg N , Shah K
Published: March 2021

Introduction

Patients with cognitive impairment are at risk of underassessment and inadequate management of pain. Self-reporting is unlikely to be a reliable indicator of pain and numerical scales have reduced validity, hence an alternative assessment tool must be used. The Abbey Pain Scale is widely regarded to be user friendly. Regular analgesia should be used for these patients where possible instead of “as required” (PRN). Using QIP methodology, we aimed to improve the use of the Abbey Pain Scale for assessment of patients with cognitive impairment and better analgesia prescribing.

Methods

Audit of patient records on COOP wards (computer and physical notes, n = 48 first cycle, n = 32 second cycle) before and after staff training, assessing patients with cognitive impairment for: use of Abbey Pain Scale; use of regular paracetamol; pain assessments documented by different healthcare professionals.

Results

In the first cycle, 16 patients had cognitive impairment: only 1 of these patients (6%) was assessed using the Abbey Pain Scale. Group teaching for the multidisciplinary team on pain assessments was undertaken with practice development nurses. In the re-audit, 13 patients had cognitive impairment and 6 of these (46%) were assessed using the Abbey Pain Scale, showing a clear improvement following staff training. The second cycle showed a 50% increase in the prescription of regular paracetamol for patients with cognitive impairment. There was also a 2.5-fold improvement in therapy staff documenting pain assessments between the two audits.

Conclusions

Staff training in the use of the Abbey Pain Scale led to an almost 8-fold increase in its use for patients with cognitive impairment. Training on the use of the Abbey Pain Scale should be regularly provided to nurses, physiotherapists and doctors on the care of the older person wards.
94 The Comprehensive Frailty Assessment At Forth Valley Royal Hospital (FVRH) Digitalised: For COVID-19 and Beyond!
Authors: Rodgerson M J , McNeil L
Published: March 2021

Introduction

Comprehensive Geriatric Assessment (CGA) improves outcomes for frail patients; at FVRH this is delivered by the Frailty Intervention Team (FIT) comprising of senior nurses, allied health professionals (AHPs) and doctors. Faced with COVID-19, we took the opportunity to digitalise CGA documentation to preserve these benefits for patients whilst facing greater acuity, staffing and time pressures. An electronic solution was adopted to reduce paper-usage in COVID-receiving areas. Prior to COVID-19, CGA was recorded within case-notes, presenting challenges when patients were readmitted out-of-hours as these were stored off-site and not accessible out-of-hours.

Method

Trakcare is the patient-management system in many Scottish hospitals. The Electronic Patient Record (EPR) was used to record pro-forma against admissions which were accessible and updatable for any patient 24–7-365. Patients meeting the Healthcare Improvement Scotland (HIS) Frailty criteria were considered “frailty-positive”, with an e-alert added- reappearing on any re-admission. Providing no HIS-exclusion criteria, an electronic-CGA (e-CGA) was recorded or updated. The pro-forma designed contained information not immediately available to clerking practitioners. This evolved following discussion amongst the FIT to include information such as escalation-status, medication-arrangements and baseline cognition.

Results

Over 13 weeks, 116 EPRs were reviewed. During weeks 1–3 (n = 8, 12, 7 respectively), e-CGA completion averaged 31%. Following FIT collaboration, this rose to 82% (n = 9) by week 12. Qualitative feedback from the MDT indicated that FIT, downstream wards and night-staff felt that having access to previous escalation-plans made immediate-management easier to determine, and discussions with families more productive for patients.

Conclusions

Development of the FVRH e-CGA is ongoing, with an electronic frailty-screening tool being implemented to improve frailty-identification on admission to ensure correct streaming of patients to the FIT. We have demonstrated a cost-neutral method for improving access to CGA for patients using existing IT systems whilst protecting staff time, preserving patient care during the COVID-19 pandemic.
99 Heritability of Temperature and the Effects of Ageing on Temperature Regulation: An Observational Multi-Cohort Study
Authors: Penfold R S , Zazzara M B , Österdahl M F , Veenith T , Lord J M , Steves C J
Published: March 2021

Introduction

Ageing affects homeostasis and immunosenescence, resulting in aberrant fever and immune responses to infection in older adults. This study assesses heritability of basal temperature and explores effects of ageing on basal temperature and temperature in response to SARS-CoV-2 infection.

Methods

Observational study using multiple cohorts. Participants: (a) Twin volunteers: 1089 healthy adults enrolled in Twins-UK, mean age 59 (17); tympanic temperature measurements; (b) Community-based: 3972 adults using the COVID Symptom Study mobile application, age 43 (13); self-reported test-positive for SARS-CoV-2 infection; self-reported temperature measurements; (c) Hospitalised: cohorts of 520 and 757 adult patients with emergency admission to two teaching hospitals between 01/03/2020–04/05/2020, age 62 (17) and 68 (17) respectively; RT-PCR-confirmed SARS-CoV-2 infection.

Analysis

(a) heritability analysed using saturated and ACE univariate models; linear mixed-effect model for associations between basal temperature and age, sex and BMI. (b&c) multivariable linear regression for associations between temperature and age, sex and BMI; multivariable logistic regression for associations between fever(>/= 37.8°C) and age, sex and BMI.

Results

Basal temperature in twins demonstrated 50% heritability (95%CI[42–57%]). In healthy twin, community-based and hospitalised cohorts, increasing age is associated with lower temperatures, and increasing BMI with higher temperatures: (a) Twins (age:p < 0.001; BMI:p = 0.002); (b) Community-based (age: p < 0.001; BMI: p < 0.001); (c) Hospitalised (1st hospital: age: p = 0.106; BMI: p = 0.033; 2nd hospital: age: p < 0.001; BMI: p = 0.010). Increasing age was negatively and BMI positively associated with fever (1st hospital: Age: OR = 0.99, p = 0.033; BMI: OR = 1.00, p = 0.045; 2nd hospital: Age: OR = 0.99, p = 0.010; BMI: OR 1.02, p = 0.038).

Conclusions

Heritability of basal temperature suggests a genetic component to thermoregulation. Associations observed between increasing age and lower temperatures and higher BMI and higher temperatures are important in understanding effects of ageing and obesity on basal temperature and the fever response. In older adults, findings have important implications for defining fever thresholds and diagnosing infections, including SARS-CoV-2.
118 “The Elderly LBGTQ* Population”
Authors: McCormack R S
Published: March 2021

Introduction

With an aging population, there will be an aging LBGTQ* population. Little education exists for medical professionals on their specific healthcare needs; the discrimination that still exists towards this group and the barriers they face when accessing healthcare. This project aimed to develop and deliver education sessions for medical professionals on “The Elderly LBGTQ* Population” in NHS Forth Valley, evaluating the quality of these sessions. With clinicians attending these sessions, it could lead to safer, more accessible and improved patient care for elderly LBGTQ* patients.

Methods

“The Elderly LBGTQ* Population” session was developed through research of relevant literature and liaising with local equality and diversity team. Two sessions were delivered in Autumn 2019. Data on quality of session was collected from feedback forms completed by those attending. Comments on feedback forms were used to shape future direction of sessions.

Results

77% of those attending felt it was of high relevance to them, with 95% rating presentation quality and content quality as “high”. Comments received included the sessions being “excellent and thought provoking”, with many stating this was their first time receiving such teaching and were grateful for highlighting the specific issues facing this population.

Discussion

Following the success of education sessions, the aim is to deliver more locally and expand across Scotland, hopefully with involvement from third sector organisations working with this population. Feedback will again be gathered to allow for continued development of sessions and ensure they remain of high quality and relevance. An e-Learning module is also in development with Association for Elderly Medicine Education, allowing for UK wide access.