bluuebunny/crossref_metadata_2025 huggingface dataset:
Day-ahead Multi-objective Coordinated Optimization Strategy for Regional Scale Source Network Load Storage System
Authors: Luo S Q , Ding X H , Han T
Published: March 2021

The regional scale source network load storage coordination system is an effective organization form to increase the proportion of clean energy and absorb distributed renewable energy. However, due to the different ownerships of various distributed resources in the system, balancing the interests of different stakeholders in the operation is an important issue to be considered. The types of distributed resources contained in the regional scale source network load and storage system and their belongingness are analyzed in different perspectives, and then the optimal operation strategy of distributed resources is proposed to balance the interests of different stakeholders. Based on this strategy, a bi-layer optimization model with energy supply cost minimization and the power consumption satisfaction maximization is established. It takes the power supply of the energy supplier and the power demand of consumer as the correlation variable of the upper and lower layer models, the analytical target cascading (ATC) theory is used to adjust the correlation variables iteratively until the power supply meets the power demand, and obtains the distributed resources trade-off operation plan satisfying different objectives. YALMIP modeling tool is used to call CPLEX solver on MATLAB platform to solve the model in parallel. An example based on the data of a regional scale source network load storage system shows that the optimization model and its solution strategy can effectively balance the optimization objectives of different stakeholders.
Study on the removal methods of plankton in micro-polluted reservoir water
Authors: Yang Hui , Tong Xin
Published: March 2021

In recent years, water pollution and eutrophication are becoming increasingly serious, plankton represented by Cyclops and algae frequently appear in many urban micro-polluted water sources. The current methods to remove algae include catching, adding algicide, adding oxidant, enhanced coagulation and so on, and the current methods to remove the Cyclops include adding oxidant, coagulant precipitation treatment, biological activated carbon filtration, etc. This paper analyzes the effect of different methods on removing plankton in the water, and their advantages and disadvantages, to solve the problem of algae and Cyclops due to seasonal reasons for short outbreaks.
Experimental Research on Treatment of Methylene Blue Wastewater by Fe3O4-MnO2 Fenton System
Authors: Li Yafeng , Li Jiacheng , Man Xinqi
Published: March 2021

In order to broaden the processing conditions of the Fenton method, under the premise of adding a catalyst, the operating conditions of the Fenton-like system were studied. When studying Fe3O4-MnO2-PAC composite material as a catalyst,this experiment find the influence of different single factors on the Fenton-like system. Research shows that when the pH is 2-5, the dosage of Fe3O4-MnO2-PAC is 800mg/L, the dosage of H2O2 is 0.8mol/L, the reaction temperature is 10°C-50°C, Fe3O4-MnO2-PAC catalyst. When used less than five times, it has a better degradation effect on methylene blue wastewater.
Adverse Perinatal Outcomes Predicted by Prenatal Maternal Stress Among U.S. Women at the COVID-19 Pandemic Onset
Authors: Preis Heidi , Mahaffey Brittain , Pati Susmita , Heiselman Cassandra , Lobel Marci
Published: March 2021

Background

High stress prenatally contributes to poor maternal and infant well-being. The coronavirus disease 2019 (COVID-19) pandemic has created substantial stress for pregnant women.

Purpose

To understand whether stress experienced by women pregnant at the beginning of the pandemic was associated with a greater prevalence of adverse perinatal outcomes.

Methods

Pregnant women across the USA aged ≥18 years old enrolled in a prospective cohort study during the pandemic onset (T1) in April–May 2020. This report focuses on the 1,367 participants who gave birth prior to July–August 2020 (T2). Hierarchical logistic regression models predicted preterm birth, small for gestational age infants, and unplanned operative delivery from T1 stress, sociodemographic, and medical factors.

Results

After controlling for sociodemographic and medical factors, preterm birth was predicted by high prenatal maternal stress, delivering an infant small for gestational age was predicted by interpersonal violence and by stress related to being unprepared for birth due to the pandemic, and unplanned cesarean or operative vaginal delivery was predicted by prenatal appointment alterations, experiencing a major stressful life event, and by stress related to being unprepared for birth due to the pandemic. Independent of these associations, African American women were more likely than other groups to deliver preterm.

Conclusion

Pregnant women who are experiencing high stress during the COVID-19 pandemic are at risk of poorer perinatal outcomes. A longitudinal investigation is critical to determine whether prenatal maternal stress and resulting outcomes have longer-term consequences for the health and well-being of children born in the midst of the current pandemic.
6 Geriatric Medicine in Undergraduate Written Assessments: Is There A Single Best Answer?
Authors: Reid M D
Published: March 2021

Introduction

It is increasingly important for new medical graduates to be knowledgeable and skilled in the care of older people. Single best answer questions (SBAQs) form the basis of written assessments in undergraduate courses but key areas of geriatric medicine have been shown to be underrepresented in medical school assessments (A L Gordon et al. Age and Aging 2010, 39:3, 385–388). This may contribute to a Hidden Curriculum that portrays geriatric medicine negatively amongst medical students (A Meiboom et al. Gerontology & Geriatrics Education 2014, 36:1, 30–44).

Methods

1133 questions for third year medical students were reviewed. Questions labelled as assessing “Geriatrics” were analysed for their relevance and content when compared to the British Geriatric Society’s (BGS) Recommended Undergraduate Curriculum in Geriatric Medicine. Remaining questions were reviewed by topic to consider if they aligned with the BGS curriculum.

Results

120 of 1,133 questions (10.59%) were labelled as assessing “Geriatrics”. Thirty-six (3.18%) of these questions covered outcomes specified in the BGS undergraduate curriculum. Questions were often inappropriately labelled as assessing “Geriatrics” due to patient age or association with certain pathologies. Of the remaining 1,013 questions, 27 (2.38%) focussed on topics outlined in the BGS undergraduate curriculum. In total 63 (5.56%) of 1,133 questions directly related to geriatric medicine. Many aspects of the BGS undergraduate curriculum including elder abuse, polypharmacy and frailty were not covered by the question bank.

Conclusions

Geriatric medicine continues to be underrepresented in SBAQs and is often misleadingly portrayed in analyses of question banks due to incorrect generalisations based on patient age or pathology. SBAQs may not be suitable for testing the knowledge and skills required in the effective care of older people and new assessment methods that better test these domains may be required. Improving the methods in which geriatric medicine is assessed at an undergraduate level may in turn counter negative attitudes that exist within a Hidden Curriculum for medical students.
7 The Elephant in the Room: An Innovative and Effective Approach to Multidisciplinary Advance Care Planning Training
Authors: Owen L , Steele A , Goffe K , Pleming J
Published: March 2021

Background

Exploring patients’ preferences for future care is known to reduce adverse health outcomes, limit transfers between care settings institutionalisation and improve quality of life. Patients value opportunities to have honest conversations.

In the recent “Talking about Dying” report from the Royal College of Physicians (RCP), it was found that healthcare professionals (HCPs) find it challenging to start conversations with patients and families. Yet the report highlights a need for HCPs to be equipped with the skills and confidence to provide opportunities for advance care planning in primary care, inpatient and outpatient settings.

Methods

A multi-disciplinary faculty delivered simulation sessions to 115 candidates (50.4% doctors, 33% nurses and 16.5% allied health professionals) from primary and secondary care.

Eight half-day sessions have taken place across North London. Each session started with an introductory lecture, followed by simulated scenarios between a professional actor and candidate within small multi-disciplinary groups. Group discussion was facilitated and feedback given.

We focused on acknowledging the progressive, complex and unpredictable nature of frailty. Scenarios included resuscitation, re-admission to hospital, risk feeding, complex discharge planning and cultural values in older adults.

Results

100% would recommend this multidisciplinary simulation to teach advance care planning.

Only 15.6% of candidates felt confident or very confident with conversations; this improved to 90.5% following the simulation and was maintained at 69.5% three months later. Understanding when advance care planning is appropriate improved from 70% to 100%. Three months after the training, 86% stated they had a sustained change in practice in ACP as a result of the course.

Conclusion

We have demonstrated that our multidisciplinary simulation is an effective format of improving understanding and confidence in having advance care planning conversations. These results are evident both immediately after and at the three month follow up stage demonstrating a sustained change in practice.
12 Being Non-Frail and Free From Cardiovascular Disease Reduces COVID-19 Risk in 269,164 Older UK Biobank Participants
Authors: Masoli J , Atkins J , Delgado J , Pilling L , Melzer D
Published: March 2021

Background

Older adults are at increased risk of COVID-19, resulting in public health shielding measures for all adults over 70 in the UK. Frailty has been proposed for risk stratification in COVID-19 with limited evidence. Cardiovascular risk factors hypertension, diabetes and raised BMI have been associated with increased COVID-19 risk. We sought to test if non-frail older adults with low cardiovascular risk had reduced COVID-19, to inform targeted shielding policies.

Methods

Fried and Rockwood frailty were ascertained at UK Biobank baseline (2006-2010) and electronic frailty index(eFI) in primary care data to 2017*. A cardiovascular disease risk score(CRS) consisting of smoking status, LDL-cholesterol, blood pressure, BMI, fasting glucose and physical activity was estimated at baseline. Frailty (baseline and eFI; eFI alone) and CRS were tested in logistic models against COVID-19 status and COVID-19 mortality to 14th June 2020 adjusted for demographics and technical covariates.

Results

N=269,164 UKB participants aged ≥65 at baseline (≥75years in 2020). 13.9% of COVID-19 positive were non-frail with low baseline CRS versus 41.8% frail with moderate/high CRS. Being non-frail and having low CRS were independently associated with reduced COVID-19. The composite of non-frail with low CRS compared to frail with moderate/high CRS had significantly reduced COVID-19 risk (composite non-frail with low CRS HR 0.61; 95% CI 0.45-0.84; p=0.0023; eFI non-frail with low CRS HR 0.16; 95%CI 0.07-0.36; p value=9.9x10-6) and COVID-19 mortality (composite non-frail HR 0.28; 95% CI 0.10-0.82; pvalue=0.02; eFI non-frail 0.07; 95% CI 0.02-0.28; pvalue=0.00014).

Conclusion

These results show that the COVID-19 risk in non-frail older adults with low cardiovascular risk was up to 84% lower than in those who were frail with cardiovascular risk factors. This could contribute to future work on stratification of shielding risk in older adults in future COVID-19 surges. *Planned data updates prior to the conference should enable updates to 2020.
26 Introducing the Sherpa Model for Managing Multi-Morbidity to Trainee GPS: Outcomes and Relevance to Elderly CareÂ
Authors: Swancutt D , Jack E , Neve H , Tredinnick-Rowe J , Axford N , Byng R
Published: March 2021

Background

Primary care trainees are traditionally taught to use a consultation model which focuses on eliciting the patients’ main reason for consulting “today”. As the number of patients with multi-morbidity increases, this approach is often inappropriate or unhelpful. Patients can be left without an understanding of their interacting health issues. The SHERPA model provides a biopsychosocial framework for consulting patients with multi-morbidity. We aimed to examine the responses to this model when integrated into a training programme for newly registered GPs.

Methods

Sixteen participants provide qualitative data on their experience and follow-up use of SHERPA. Four hours of teaching were observed. Twenty-four feedback templates on training (n = 18) and SHERPA application (n = 6) were collected. Individual semi-structured one-to-one interviews were conducted with trainees (n = 5) and trainers (n = 3). Data were transcribed and, using the Framework approach, systematically analysed focussing on the trainees’ reaction to the teaching sessions and their ability to use the SHERPA consultation model.

Results

Participants engaged well with the teaching sessions, enjoying the scenarios and bringing observations from their own experience. Five participants went on to apply SHERPA successfully with their patients. Barriers to using this approach were: not seeing appropriate patients with multi-morbidities (due to current placement or patient type); time; lack of confidence and familiarity; concern about missing important immediate clinical issues; and viewing the approach as “in addition” rather than key to shared decision-making.

Conclusion

The SHERPA model was viewed as a helpful addition by trainee GPs, although practical issues, fears and not seeing it as their priority for their case-mix, limited their application of it. Regular support from trainers, where trainees reflect on their experience of using SHERPA, could increase their confidence and familiarity with this method. These findings suggest that SHERPA may be relevant to other specialities such as geriatric medicine, where multi-morbidity is common.
28 Medication Compliance Aids and Acute Hospitals
Authors: Mclachlan S , Chakravorty M , Odone J , Stevenson J , Minshul J , Schiff R
Published: March 2021

Introduction

An estimated 64 million Medication Compliance Aids (MCAs) are dispensed by pharmacies in England each year as a method of reasonable adjustment to improve medication adherence (NICE 2009) and support medicines administration by carers (RPS 2013). Complexities exist when implementing medication changes for patients using MCAs, particularly at hospital discharge or outpatient appointments, where practices seem to vary. This National Survey is the first to determine the current policy and service provision of MCAs by acute hospitals in England.

Methods

An electronic survey was emailed to Chief Pharmacists via the Regional Medicines Information Services in Spring 2019. Initial non-responders were contacted by email and telephone.

Results

51% (73/144) of acute hospital trusts in England responded. 77% (56/73) dispensed medication in MCAs at discharge. Of these, 62.5% would initiate MCAs and 61% supplied a different length of MCA vs non-MCA prescription (see table).

41 hospitals had designated staff completing MCAs. The median time to complete an MCA was 59.5 minutes (range 10–200). The median time from prescription receipt in pharmacy to MCA arrival on ward was 144.5 minutes (range 60–1,440).

Of the 17 hospitals not providing MCAs, the majority would, upon discharge, contact the community pharmacy that provided the MCA pre-admission to update any medication changes and request the provision of a new supply of medicines.

Conclusion

Despite the ubiquitous nature of the MCA, there is no standard approach to the supply of these devices from acute hospitals across England. When hospitals do provide MCAs their preparation is time consuming, often requiring additional staff. A national approach to MCAs might help patients and carers, and reduce medication-related problems and costs.
30 Informant-Reported Decline Associates with Silent Acute Stroke Lesions and Worse Small Vessel Disease in Mild Stroke Patients
Authors: Clancy U , Garcia D J , Hewins W , Stringer M , Thrippleton M , Chappell F M , Brown R , Blair G , Arteaga C , Valdes-Hernadez M , Wiseman S , Hamilton I , Job D , Doubal F N , Wardlaw J M
Published: March 2021

Introduction

Small vessel disease (SVD) commonly causes stroke and dementia. Early clinical predictors of disease progression are lacking. We aimed to determine whether informant reports of chronic cognitive/functional decline, prerequisites for dementia diagnosis, are associated with (a)baseline SVD burden, measured by Fazekas scores and (b)SVD change, measured by incident subcortical Diffusion-weighted Imaging (DWI) lesions.

Method

We prospectively recruited patients with mild ischaemic stroke, performed diagnostic MRI, and invited participants to repeat MRI 3- to 6-monthly. Informants completed the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) prior to baseline visit, a 16-item questionnaire which assesses patients’ cognitive and functional decline in the preceding ten years. Scores range from 1–5: a score above 3.3 has high sensitivity/specificity for dementia post-stroke. We conducted linear regression with IQCODE as the dependent variable, adjusting for age, sex, baseline MoCA, disability (modified Rankin Scale).

Results

We recruited 106 participants (mean age 67 years;range 40–86;33% female). Ninety-three informant questionnaires were returned. IQCODE associated with baseline Fazekas score; Fazekas 6 (β = 0.28, p = 0.04) vs. Fazekas 3 (β = 0.03, p = 0.67), R2 = 0.11, adjusted for age, sex, baseline MoCA, disability.

Incident DWI lesions were common (15/106; 14/15 subcortical; no active embolic sources; median 67 days post-stroke). Four were asymptomatic, two reported stroke-like symptoms and nine had neuropsychiatric/non-focal symptoms. IQCODE was higher in those with a new lesion vs. without (β = 0.21, p = 0.02), R2 = 0.09, while age (β = −0.004, p = 0.19), MoCA (β = −0.006, p = 0.56) and disability (β = 0.06, p = 0.2) were not.

Conclusions

Higher SVD burden and incident, mostly “silent” stroke lesions associate more strongly with informant concerns of cognitive/functional decline than age or objective cognitive tests. These findings are novel in an ischaemic stroke population and the first to assess IQCODE/SVD progression. Future work should determine whether combining informant reports with imaging features of small vessel disease improves early detection of dementia.
31 Physical Activity, Muscle Strength and Quantity: Preliminary Findings From the Mass_Lifecourse Cohort
Authors: Bowden-Brown K J , Murray J C , Hurst C , Granic A , Sayer A A , Dodds R M
Published: March 2021

Introduction

We established the MASS_Lifecourse study to investigate changes in skeletal muscle between ages 45–85. Reduced physical activity (PA) is a key factor linked to the development of sarcopenia. Our aim was the describe the amount and patterns of PA and sedentary behaviour (SB), and relationships with muscle strength and quantity, among MASS_Lifecourse participants.

Method

Participants wore a triaxial accelerometer on their dominant wrist for seven days. Recordings were analysed to calculate time in moderate-vigorous PA (MVPA) with time not in MVPA classified as SB based on wrist position. Muscle strength was measured with a Jamar grip dynamometer and the 5 chair-stand test. Muscle quantity was assessed using appendicular lean muscle mass from dual-energy X-ray absorptiometry. Physical performance was assessed by gait speed.

Results

68 participants (31 male) aged 47–84 (mean 65) participated in the present study. Median daily MVPA was 19.1 (IQR 7.1, 36.6) minutes and was lower with age. The mean sedentary time per day was 767.1 minutes per day and increased with age. The pattern of MVPA across the day changed with age: the oldest group (75–84 years) achieved a lower morning activity peak followed by an earlier decline whilst the younger groups were more consistently active throughout the day. Participants were more active than population reference data from the Active Lives Survey. Time spent in MVPA was positively associated with muscle strength and physical performance, whereas SB was negatively associated. Muscle quantity was not associated with PA or SB.

Conclusions

Participants in the MASS_Lifecourse study are more active than the general population but still show age-related declines in physical activity and strength. Future work in the cohort aims to elucidate mechanisms underlying the age-related loss of muscle strength and quantity.
37 Factors Influencing Mealtime Care for People with Dementia Living in Care Homes: An Ethnographic Study
Authors: Faraday J , Abley C , Exley C , Patterson J
Published: March 2021

Introduction

More and more people with dementia are living in care homes. Often they depend on care home staff for help with eating and drinking. It is essential that care home staff are able to provide good care at mealtimes. This study used ethnography to identify factors influencing mealtime care for this population.

Methods

Over twenty-five hours of mealtime observations were conducted in two UK care homes with diverse characteristics. Observations focused on interactions between care home staff and residents living with dementia. Twenty-two semi-structured interviews were carried out with care home staff, family carers, and visiting health and social care professionals, to explore mealtime care from their perspectives. The study used a constant comparison approach, so that data from early observations and interviews were explored in more depth subsequently.

Results

Five factors were identified which influenced mealtime care for people with dementia living in care homes. These were: environment (such as background music and building layout); kitchen and food (including connectivity between kitchen staff and others); staffing (for example: staff ratios and allocation); knowledge and support (including training, resources and supportive culture); and relationship with wider care team (such as family involvement, and the role of visiting health and social care professionals).

Conclusions

This study is part of a bigger project which will develop a staff training intervention to improve mealtime care for people with dementia living in care homes. The intervention will be informed by these findings, and by complementary evidence on good practice in mealtime care (from primary and secondary studies). It is anticipated that good mealtime care may improve quality of life for care home residents, and reduce hospital admissions.
40 Improving Urinary Catheter Documentation and Care in Geriatric Wards
Authors: Costa A V , Zhunus A , Storey B , Sait M S , Shah S , Sanei F , Mathew J , Heitor M
Published: March 2021

Introduction

NICE guidelines state that urinary catheter insertion, changes and care should be documented. Duration of catheterization is directly linked to the risk of developing a catheter-associated UTI. Furthermore, Public Health England has announced a national aim to reduce the incidence of Gram-negative bacteraemia by 50% by March 2021, and targeting catheters is one of the first steps.

Local problem

These issues are relevant to the elderly population at Princess Royal University Hospital, where documentation surrounding catheters was found to be inadequate. Despite there being an Electronic Patient Record (EPR) order for catheter insertion and monitoring available, this was not being used. Our primary aim was for all patients to have this order. We also hoped to reduce the weekly rate of catheter days (catheter days per 100 bed days), and improve documentation in clinical notes.

Methods

We focused on two medical wards and sampled all patients admitted over a period of 4 months who had a catheter at the time of data collection. We identified catheterized patients and whether they had an EPR catheter order on a daily basis. Additional parameters such as indication, insertion date, inserter, and documentation standards were extracted from EPR on a weekly basis. Patients were kept “live” and contributing to catheter day calculations until they were no longer on the ward or if the catheter was removed.

Interventions

We implemented changes over 2 PDSA cycles. Interventions included the addition of catheter columns to boards and education sessions for doctors and nurses (cycle 1), as well as catheter posters, alert cards, and circulation of emails with guidance to doctors and nursing staff (cycle 2).

Results

A total of 87 patients were analysed during the project. There was an increase in EPR orders being used, with the 100% target being reached on the final data collection point, and with data showing a significant shift above baseline. Furthermore, there was a decrease in the weekly rate of catheter days, but changes were difficult to sustain. We also saw a general improvement in documentation standards.

Conclusion

By improving documentation and reducing unnecessary catheterization, we hope to have reduced the overall risk of infection whilst improving patient comfort and experience. Lessons may be transferrable to other trusts.
49 Longitudinal Change of Sleep in the Elderly and Its Associations with Health
Authors: Didikoglu A , Maharani A , Payton A , Canal M M , Pendleton N
Published: March 2021

Introduction

In elderly populations, sleep quality deteriorates and sleep time shifts towards earlier times. These sleep characteristics have been associated with cardiovascular, metabolic and psychiatric disorders, cognitive decline and mortality. Our aims are to examine longitudinal changes of sleep in older adults and to investigate the relationship between sleep variations, general health and mortality.

Methods

The University of Manchester Longitudinal Study of Cognition in Normal Healthy Old Age cohort (6,375 participants, recruited in the North of England, between 1983 and 1993) was used. Mixed models were used to investigate individual sleep trajectories (5 waves in 30-year period). Sleep timing and efficiency trajectories were clustered using latent class analysis and analysed against daily habits, health and mortality.

Results

Older adults have decreased sleep efficiency (~20%) and early sleep time (~30 min) between 40 and 100 years of age. Those in the high sleep efficiency latent class had minimal decrease in their sleep efficiency as they aged. Belonging to the high sleep efficiency latent class was associated with having lower prevalence of hypertension, circulatory problems, arthritis, breathing problems and recurrent depression compared to the low efficiency latent class. Results showed a higher risk of hypertension and metabolic syndrome in the evening-type latent class compared to morning-type individuals. Evening class was associated with traits related to lower health such as reduced sport participation, increased risk of depression and psychoticism personality, late eating, increased smoking and alcohol usage. Survival analysis revealed that individuals in the evening class had 1.15-fold increased risk of all-cause mortality compared to those with morning preferences.

Conclusion

Ageing is associated with decreased sleep efficiency and early sleep timing. However, there are detectable subgroups of sleep traits that are related to prevalence of different diseases and longevity. Understating these subgroups may pave the way for new treatments for healthy sleeping habits in older population.
140 Lessons From the Front Line: Communication is Key
Authors: Pyrke B , Abdalla B , Cartwright G , Figg K , Murphy E , Tuck A , White H
Published: March 2021

Introduction

As junior doctors, we very rarely receive formal teaching on communication after medical school, with telephone encounters and difficult conversations over technology being a vital yet missing part of our education. The COVID-19 pandemic has required us to adapt how we communicate with patients’ families due to hospital visiting restrictions. In an era where tragically deterioration and death have been much more commonplace, we looked to identify areas where junior doctors felt their communication skills could be improved, and implemented a teaching programme to deliver this.

Methods

Pre-teaching questionnaires were distributed to a range of grades of junior doctors working in University Hospital of Llandough, Cardiff. The questionnaires were distributed at the beginning of June 2020, after 3 months of working in pandemic conditions. A teaching session on telephone and video communication skills was delivered by a local palliative care consultant. Post-teaching, a repeat questionnaire was undertaken to assess response and identify key learning points.

Results

Pre-teaching, 100% of the 22 respondents had had to participate in difficult conversations over the phone, 82% had had no formal phone based communication skills training and 81.82% felt some form of formal teaching would be helpful. Post-teaching, 12 junior doctors provided feedback with an average 37% increase in confidence to undertake difficult conversations. Key learning points from the session highlighted the importance of preparation, regularly updating the family to build trust and rapport, and integrating family updates via tele-communication into daily ward life.

Conclusions

Education around telephone communication skills is critical to enable us to adapt our skills in accordance with the demands of the pandemic, to continue to support relatives and to engage with technology with confidence. Increased preparation is required to navigate difficult conversations via technology, and successful communication requires clinicians to take responsibility for initiating regular family updates.
142 Improving Functional Outcomes During Covid-19 for Both COVID-19 and Non COVID-19 Positive Older Adults Through the Introduction
Authors: Roberts F , Birmingham K , Darlison L , Hertzberg K , Chapman K , Krampikowski J , Bunden D , King L , Tebbutt E , Potter E
Published: March 2021

Purpose

To improve the functional outcomes of older adults presenting to the Health and Ageing wards during the COVID-19 pandemic through a focussed rehabilitation list. The intended benefits to the older adult and service were for: 1. Daily rehabilitation input for older adults. 2. Older adults to spend less time immobile. 3. Ongoing rehabilitation intervention while awaiting medical clearance for discharge. 4. Increased staff satisfaction 5. Better outcomes on discharge. 6. Rehabilitation ethos on the Health and Ageing wards.

Methods

The quality improvement project was carried out using the Plan, Do, Study, Act (PDSA) cycle. Three iterative PDSA cycles were carried out over the course of the project to deliver proactive interventions as a result of analysis of baseline data and stakeholder involvement. These interventions were aimed at developing communication around the rehabilitation list within the team and sustainability of this list.

Results

The project resulted in better functional outcomes for older adults and increased staff morale. Between May 2020–June 2020, a total of 56 patients were seen on the rehabilitation list, with 84% of these patients seeing improvements in their Elderly Mobility Scores (EMS). 27% of patients on the rehabilitation list saw a change to their initial discharge plan, either needing reduced packages of care or reduced need for ongoing rehabilitation in an external setting.

Conclusions

The quality improvement project found that with focussed rehabilitation older adult inpatients with or without COVID-19 can make significant functional gains. These gains have wider effects on their outcomes on discharge and also for the service through increased morale and job satisfaction. Due to demand and capacity issues in the acute setting, older adults who would often benefit from ongoing input are not always reviewed regularly. This project demonstrates that with focussed rehabilitation older adults can improve and achieve better functional outcomes.
145 Improvement of Bowel Monitoring in the Acute Stroke Unit
Authors: Yip S Y
Published: March 2021

Introduction

Constipation can lead to complications such as pain, acute kidney injury and delirium. This problem is more apparent in patients who are aphasic or frail, such as those suffering from stroke or have cognitive impairments. However, early recognition and timely prescription of laxatives can help prevent these complications and prevent unnecessary Per-rectal examination and exposure from radiation with abdominal X-rays.

Methods

This is a Quality Improvement Project that was carried out in the Acute Stroke Unit in Aberdeen Royal infirmary looking at the effectiveness of bowel monitoring and suggesting methods for improvement with the addition of an end-of-bed stool chart. The aims of the stool charts were to aid junior doctors in timely laxative prescription and to guide fluid management. The project was carried out from April to July 2020 using the PDSA cycle and presented to MDT in the ASU. Results show a 100% improvement in bowel monitoring with 67% compliance rate of the new stool charts.

A survey was carried out and results show that 90% of the nursing team preferred the new stool chart. In conclusion, I think that the new stool chart serves its purpose in improving patient management amongst junior doctors. It should be implemented as standard care protocol in the acute stroke unit and definitely can be applicable in other wards.
146 Improving Outcomes in Aspiration Pneumonia: A Collaborative Approach
Authors: Richards-Taylor S , Kitchener R , Whiffen M , Tiwari D
Published: March 2021

Introduction

Aspiration pneumonia is a major cause of morbidity and mortality especially in older adults. Our Trust recorded higher than expected mortality ratios in this group of patients. Aim To investigate reasons behind higher than expected mortality and improve outcomes. Intervention We developed a collaborative approach of investigating mortality in aspiration pneumonia with joint input from Speech and Language (SALT) specialists.

Method

We conducted structured retrospective review of annual mortality in aspiration pneumonia in 3 PDSA (plan, do, study, and act) cycles in 2015/18/20. We collected data on clinical care, diagnostic accuracy, SALT referral/input, feeding at risk discussion, communication with primary care. We monitored mortality ratios on national systems.

Results

We improved clinical and nursing care by auditing mouth care, bed elevation and safe feeding. We also developed electronic-SALT referral form to improve timings for the reviews (first PDSA cycle). SALT team developed “feeding at risk proforma” to formalise risk feeding where safe swallow plan was not possible (second PDSA cycle). We modified discharge summaries and made this a multidisciplinary document in the Trust so that SALT can communicate feeding plans to primary care (third PDSA cycle). Mortality ratios improved significantly in this period from Relative risk of 152 (higher than expected range) in 14/15 to 86 (within expected range) in 19/20.

Conclusion

We have demonstrated significant improvement in hospital mortality ratios from aspiration pneumonia and therefore improved care by collaboratively working with SALT team and bringing changes in stepwise manner. Multidisciplinary mortality reviews are key to improving outcomes for our patients.
151 Optimising Bone Health on Sheffield Frailty Unit Through Quality Improvement
Authors: Orton C M , Sinson N E , Blythe R , Hogan J , Vethanayagam N A , Peel N
Published: March 2021

Introduction

NICE and the National Osteoporosis Guidance Group (NOGG) advise on evaluation of fracture risk and osteoporosis treatment1,2, with evidence suggesting that screening and treatment reduces the risk of fragility fractures 3,4,5. However, it is often overlooked in the management of older patients within secondary care. Audit data from Sheffield Frailty Unit (SFU) in 2018 showed that national guidance was not routinely followed. Fracture Risk Assessment Tool (FRAX®) scores were not calculated and bone health was poorly managed. Therefore, we undertook a quality improvement project aiming to optimise bone health in patients presenting to SFU.

Method & Intervention

In January 2019 we collaborated with Sheffield Metabolic Bone Centre (MBC) to develop a pathway aiming to improve bone health assessment and management in patients presenting to SFU with a fall or fragility fracture. This included a user-friendly flow chart with accompanying guidelines, alongside education for staff. Performance was re-evaluated in May 2019, following which a tick box prompt was added to post take ward round documentation. A re-audit was performed in March 2020.

Results

In March 2018 0% of patients presenting with a fall had a FRAX® score calculated and only 40% of those with a new fragility fracture were managed according to guidelines. In May 2019, this had improved to 18% and 100% respectively. In March 2020 86% of patients had a FRAX® score calculated appropriately and 100% of fragility fractures were managed according to guidelines. In both re-audits 100% of FRAX® scores were acted on appropriately.

Conclusions

There has been a significant increase in the number of patients who have their bone health appropriately assessed and managed after presenting to SFU. However, achieving optimum care is under constant review with the aim to deliver more treatment on SFU, thereby reducing the need for repeat visits to the MBC.
158 Management of Atrial Fibrillation in Patients with Cerebral Amyloid Angiopathy: Multidisciplinary Neuro-Cardiology Approach
Authors: Hashmi M A , Sheikh A A
Published: March 2021

We present two cases that highlight the clinical challenge of anti coagulation in patients with intracerebral haemorrhage (ICH) due to Cerebral Amyloid Angiopathy (CAA) and co-existent non-valvular Atrial Fibrillation (AF).

Case 1

78 -Years right-handed functionally independent gentleman presented with right parietal intracerebral haemorrhage (ICH) on Dabigatran that required reversal. He had a background history of hypertension, persistent AF and a previous ICH on warfarin. Post atrial septal defect repair, he had multiple unsuccessful cardioversions for AF, and a failed catheter ablation after the first stroke. Magnetic Resonance Imaging (MRI) brain showed Cerebral Amyloid Angiopathy (CAA), the cause of his recurrent bleeds. Anticoagulation was not started due to severe CAA on imaging and recurrent bleeds. He was referred for left atrial closure device.

Case 2

79-Years female presented with left parietal haemorrhage and new onset atrial fibrillation. Work up for ICH showed normal BP readings and clotting profile. Her MRI brain showed a large lobar bleed with mild small vessel disease and evidence of no other imaging features suggestive of CAA. As optimal timing to start anticoagulation after ICH is unknown, she was suggested to take part in a clinical trial. Her family declined the offer of clinical trial and also anti coagulation due to few falls. Her CHAD-VaSc and HAS-BLED score were 4 and 2 respectively. She was then referred to tertiary centre for left atrial appendage closure device.

Conclusion

Safety and timing to initiate DOAC for AF in this group is not established yet, understanding hemorrhagic risk using Boston Criteria for CAA diagnosis should be considered in addition to HAS-BLED score. Shared decision making and comprehensive discussions with cardiologist are of paramount importance. Non pharmacological intervention studies WATCHMAN and PREVAIL have proven procedural efficacy, however, in elderly population, decision making is complex due to frailty, dementia and co-morbidities.
51 CT Head and Cervical Spine Audit in Patients Over the Age of 65: A District General Hospital Perspective
Authors: Hadley G , Billingsley S , Nakagawa S , Durkin C
Published: March 2021

Introduction

Cervical spine (c-spine) injury has a high morbidity and mortality in patients over the age of 65; more than 60% result from falls from standing height (Beedham et al., 2019).

The Canadian Cervical Spine Rule (Stiell et al., 2001) deems that there is a high risk of c-spine fracture if any of the following apply:

The c-spine cannot be cleared clinically if the patient fits any of the above criteria. Imaging should be considered. As a result of recent clinical experiences Trust Guidelines at Stoke Mandeville Hospital now reflect this evidence (Hadley et al., 2019).

Methods

Fifty patients over the age of 65 who had a computerised tomography (CT) head scan in the Emergency Department (ED) following a traumatic head injury were randomly selected over a 1 month period. Cases were checked for examination of c-spine and/or CT c-spine. Results of the first cycle of the audit were presented at an ED Education Meeting. Indications for CT c-spine were displayed in poster format around the ED. Following these interventions, a re-audit was carried out using the same methodology.

Results

In fifty patients aged over 65 attending ED during one month, 16% had a CT c-spine in addition to a CT head. There was documented c-spine examination of 16% of those without CT c-spine on admission. In the re-audit 38% of the fifty patients who had a CT head underwent CT c-spine. In the group that did not have imaging of the c-spine, the proportion with documented cervical spine examination on admission remained the same (16%).

Conclusion

There was a 137.5% increase in the number of patients aged over 65 who appropriately underwent a CT c-spine as per Trust and National guidelines. Simple interventions (staff education and posters within the ED) were sufficient to significantly alter practice. Current trauma triage is not optimal for older patients who are reviewed by more junior doctors, less likely to be transferred to Major Trauma Centres and more likely to die than younger patients with similar injuries (Major Trauma In Older People 2017 Report). An older person’s trauma team in ED with age-appropriate triage would lead to appropriate imaging in a timely fashion, potentially improving the morbidity and mortality of these vulnerable patients.
163 Frailty, Doesn’t That Mean Birdlike? Research Into Attitudes and Understanding of Frailty in Undergraduate and Postgraduate Trainees
Authors: Hartley S , Cropp A , Fisher J
Published: March 2021

Introduction

Frailty is an increasingly recognised concept, with 25–50% of over 85’s estimated to be frail1,. Previous research considered medical students’ attitudes towards older people2, yet despite the correlation between frailty and increased age3, little is known about attitudes of healthcare professionals towards frailty.

We researched attitudes towards, and understanding of, frailty in undergraduate and postgraduate trainees, with a view to guiding future educational interventions.

Method

Approval was granted by Northumbria Healthcare NHS Foundation Trust (NHCT) Research and Development department, Newcastle University’s Research Management Group and the HRA.

3 cohorts were recruited; 3rd year Newcastle University MBBS Students, 5th year Newcastle University MBBS Students and Foundation Year 2 and Core Medical Trainees working for NHCT (junior doctors). Data was collected during scheduled teaching at NHCT and individuals were invited to participate via email prior to this. Those not participating were still required to attend the teaching. Participants provided written consent.

Within each cohort, small group discussions around frailty and Comprehensive Geriatric Assessment (CGA) were prompted using open questions (e.g. “what does frailty mean to you?”), during which participants anonymously submitted phrases to an online word-cloud generator. Discussions were audio recorded and transcribed.

Transcriptions and word-clouds were analysed using Simple Content Analysis. The over-arching themes within each cohort were identified and compared with other cohorts. Interpretations were reviewed by an independent researcher to enhance rigour.

Results

Each cohort associated frailty with older age and weakness, and often used it as a byword for complexity. Frailty was described as an abstract construct composed of personal experiences rather than an objectively defined descriptor. All associated it with negative emotions.

Cohorts differed in their approach, with 3rd year students primarily focussed on defining frailty, whereas junior doctors prioritised the clinical challenges it presented.

Junior doctors demonstrated limited understanding of CGA whilst undergraduate students were almost universally ignorant of it.

Conclusions

The lack of understanding around frailty and CGA is concerning given its high prevalence. The identification of negative emotions increases this concern. To challenge this, focussed educational interventions addressing understanding and attitudes ought to be developed for tomorrow’s doctors.

References

1. Clegg et al. Lancet 2013; 381: 752–62.

2. Samra et al. Age Ageing 2017; 46: 911–9.

3. Romero-Ortuno et al. Age Ageing 2012; 41: 684–9.
53 Development of Early Supported Frailty Discharge Team
Authors: La Thein M , Le Aung S U , Bafdhel L
Published: March 2021

Introduction

The aim of the audit is to find out whether Rockall clinical frailty score (CFS) has an effect on hospital admissions, such as length of hospital stay, readmission within 30 days after discharge. By knowing the association, we can provide early supported frailty discharge team’s service to patients with specific frailty scores to reduce 30-day readmission rate.

Method

58 patients from Geriatric wards of Southend Hospital including age, reason of admission, and Proactive Elderly Advanced Care Plan (PEACE) status were collected as a baseline. Admission status, length of hospital stay, readmission and mortality were recollected on a weekly basis in the month of October and November 2019, together with clinical frailty score documented on discharge.

Results

The analysed data was left with 37 patients, after excluding 22 patients whose clinical frailty scores not documented on discharge.

Clinical frailty score was independent of age. 85% of the patients were CFS 6 and above, 15% were CFS 4 and 5.

The mean length of stay was 15 days. The severity of frailty was directly proportionate to the average number of days spent in hospital. Patients with CFS 9 had the highest mean hospital stay of 18 compared to 22 days in the group of CFS 4.

Significant 30-day readmission rate (33%) was seen in patients with clinical frailty score of 5 and 6. Patients with upper extreme end of frailty scores were associated with mortality, 83% in CFS 9. In 5 out of 20 patients with CFS of 7 and above, PEACE was put in place. It might explain the reason why there were relatively lower readmission rates in such groups.

Conclusion

From analysis of our data collection, CFS is a good predictor of duration of hospital stay which is in line with previous studies. Severity of frailty may help indicate the likely risks and frailty-related outcomes and help to plan treatments and interventions which may decrease length of stay. As a part of quality improvement project, we are introducing community early supported discharge team to CFS 5 and above patients.