bluuebunny/crossref_metadata_2025 huggingface dataset:
668 IMPROVING ACCESS TO CALL BELLS: LESSONS FROM THE PANDEMIC
Authors: Morrow A , Knighton A
Published: March 2022

Introduction

Call bells are a simple safety measure linked to prevention of falls. The National Audit of Inpatient falls 2017 highlighted that access to call bells was highly variable across trusts and recommended regular auditing. The national average of access to call bells was 81%. The winter covid pandemic posed a significant burden on staffing levels due to absence and redeployment. Experienced nursing staff are essential to maintaining good quality care to elderly patients.

Method

We conducted an audit of access to call bells on a geriatric ward in December 2020 (mid-pandemic) compared to April 2021 (post-pandemic). Patients receiving 1:1 or cohort nursing care were not included.

Result A total of 40 patients were audited. Mean age mid-pandemic was 88.7 compared to 86.4 post-pandemic. The average frailty score was 5.4 and 5.5 respectively. 47.4% of patients mid-pandemic had a documented dementia or delirium, versus 28.6% post-pandemic. The percentage of patients with access to a call bell mid-pandemic was 42.1% compared to 85.7% post-pandemic, a statistically significant difference (χ2 = 8.3, P = 0.004). Relative risk of call bell unavailability was 4.1 times greater in the December cohort than in April (RR 4.1, 95% CI 1.3–12.4). Staffing was reported to be below expected levels in December 2020 with not all nurses/HCAs having experience in geriatric care compared to expected staffing levels of experienced ward staff in April 2021.

Conclusion

Access of call bells to elderly patients remains a simple intervention in preventing inpatient falls. In light of the threat of new covid variants and future winter pressures we remain hopeful that the importance of adequate levels of experienced nursing staff for our elderly population is not underestimated. We are currently implementing a ‘5 moments for call bell access’ quality improvement project and recommend further auditing across departments within the Trust.
672 ASSESSMENT OF THERAPEUTIC RESPONSE TO MELATONIN IN PARKINSON’S DISEASE PATIENTS WITH SLEEP DISORDERS, A QI PROJECT
Authors: Melrose R , Kershaw C , Jones E
Published: March 2022

Introduction

Holistic care of patients with Parkinson’s Disease (PD) addresses motor and non-motor features. With prevalence of around two-thirds of patients, sleep disorders; including REM Sleep behaviour Disorder (RBD); can have significant negative impact on quality of life. The naturally occurring neuro-hormone, melatonin plays a role in circadian rhythm; a process disrupted in PD. In 2017, NICE suggested to ‘consider clonazepam or melatonin to treat RBD.’ Melatonin has a more favourable side effect profile than clonazepam. This QI project qualitatively evaluates a geographical subset of PD patients treated with melatonin, assessing the clinical effect of treatment and whether this medication is being used optimally. PDSA methodology identified potential for introducing a sleep scale to allow more Objective future assessment.

Methods

A departmental database identified all current and deceased patients treated with melatonin since 2015. The electronic patient record of a total of 26 patients were reviewed. Data on indication, dosing, response (subjectively categorised as no effect, mild, moderate, or good impact) alongside demographics were collected.

Results

Analysis revealed poor sleep as the most common indication for melatonin. Melatonin was well tolerated with no reported side effects. Results showed benefit in 95% of patients with an initial dose of 2 mg. Dosing was reviewed in 81% of patients at next clinic appointment. For those patients who did not have ‘good’ effect dose was increased in 62% of patients.

Conclusion

The subjective nature of sleep assessment makes assessing therapeutic benefit challenging however data suggests melatonin does improve sleep, a finding consistent with current limited research. Implementation of a sleep scale questionnaire for patients commencing melatonin will allow Objective analysis by the multidisciplinary team of medication effect and aid dose titration. Ongoing review is required to assess effect due to the infrequency of included patients and protracted therapeutic response period.
680 IMPROVING COMMUNICATION IN THE TIME OF COVID-19 - USING A DEDICATED COMMUNICATION SHEET
Authors: Misquitta O , Angeles G , Overin D , Green L
Published: March 2022

Title Improving ease and consistency of communication with Next of Kin (NoK) on an Acute Frailty Ward.

Background

A dedicated Communication Sheet was introduced on an Acute Frailty ward at the Royal Surrey County Hospital (by a Nurse-in-Charge and foundation doctors under the supervision of a Consultant Geriatrician) to improve communication between the Multidisciplinary team(MDT) and patients’ NoK/families.

Introduction

Communication with patients’ NoK is an essential part of providing holistic care & has become important given the COVID-19 visiting restrictions. Multidisciplinary Team (MDT) members were facing difficulties in knowing the following while updating NoK: 1. The correct contact details of the Next of Kin and other significant persons involved in care. 2. When the last NoK update was done and what was discussed. 3. If the patient has consented to NoK updates. This led to dissatisfaction and complaints from families regarding the frequency and consistency of updates. To make this easier for staff, a communication sheet was introduced.

Methods

A Plan-Do-Study-Act Method: was used. Following discussion at a ward governance meet, a survey was conducted to assess the difficulty faced by MDT members in NoK updates. A Communication Sheet designed by a Nurse-in-Charge and Foundation Doctors was trialled for 1 month. The sheet was updated following feedback. A repeat Survey was conducted to assess if NoK updates were easier after the intervention.

Results

After the Introduction: of the Communication Sheets, the number of staff facing ‘significant difficulty’ in the above-mentioned parameters reduced and those facing ‘no difficulty’ increased. Feedback from MDT members suggested that they found the intervention useful.

Conclusion

Dedicated communication sheets made updating families/NoK easier. This ensures consistent updates especially when visiting is restricted. This fosters a better patient-clinician relationship. Given its success, we plan to share this with other frailty wards to scale up this intervention.
687 FLUID MANAGEMENT OF PATIENT ADMITTED IN ACUTE ELDERLY CARE MEDICINE WARD: A RE - AUDIT AND COMPARISON TO STANDARD RECOMMENDATION
Authors: Farhana T , Noble J
Published: March 2022

Introduction

There is considerable pressure for monitoring and recording of fluid intake in the elderly care unit We conducted a re-audit of our practice measured against standard recommended fluid intake and implemented measures following initial audit to determine an improvement of the patient care in our unit.

Method

A prospective analysis of recording and total fluid intake of 16 patients in a given day, data was collected from electronic records and outcomes compared to our previous audit. Standard daily fluid intake was considered in male 2000 mL and female 1,600 mL [1].

Result Patient demographics were comparable, including M: F ratio 6: 10 (previously 9: 5), median age 84.5 years (previously 85.5 years) and median clinical frailty score 6 (previously 7). Median fluid intake of male group 1,300 mL (previously 750 mL) and female group 1,000 mL (previously 700 mL). The entries of fluid recording throughout 24 hours showed day shift 81% (previously 26%), evening shift 100% (previously 95%) and night shift 94% (previously 86%).

Conclusion

There is evidence of improvement of fluid management in our unit following implementation of some measures however issue with daily fluid intake is lower than the recommended standard.

Reference

1. Fluid (water and drinks) - British Dietetic Association - UK.COM. https://www.bda.uk.com › resource › fluid-water-drinks.
694 IMPROVING OPIATE PRESCRIBING IN OLDER ADULTS WITH HIP FRACTURES TO COMBAT THE IATROGENIC FALLOUT
Authors: Hudson M A J , Atkin J , Lumley G , Singh S , Varma S , Shenoy D , Morgan C , Peck G , Fertleman M , Koizia L
Published: March 2022

Background

The number of opioid prescriptions in older patients has increased dramatically and it is recognised that opioids are the fourth most likely drug to cause preventable hospital admissions. The adverse effects of opioids occur more frequently in the geriatric population. Little is known about the impact of postoperative pain in older adults. NICE recommends paracetamol with additional opioids if there is insufficient postoperative pain relief. Multidisciplinary management with early and then daily physiotherapy is critical. We have assessed pre-morbid, immediate and prolonged use of opioids in patients following hip fracture. Local problem Pre-intervention analysis identified 79% (57/72) of all patients being discharged on opiates. At 4-months, 37% (17/46) of those were still using them. This represents 28% (17/61) of all patients.

Methods

Analysis of all patients (excluding poly-trauma) with hip fractures over the age of 60 years admitted to St Mary’s Hospital. Interventions Development of local guideline on analgesia prescribing; particularly focusing senior geriatrician led decision making. Prescribing oxycodone for first 72-hours and initially using nerve block. Avoidance of transdermal preparations and withdrawing stronger opioids prior to discharge. Clear instructions for GP’s on a stop date and need for community review. Patient information leaflet dispensed with all discharge opioid prescriptions.

Results

Post-intervention cycle; 17% (11/63) of patients were taking prescribed opioids prior to admission (similar to the pre-cohort). 52% (33/63) were discharged on opiates, down from 79%. At 4-months, of those discharged on opioids, 30% (9/30) were still using them; lower than in the first cycle (37%). Overall reduction from 28% to 16% of patients on opioids at 4-months.

Conclusion

The use of specific hip fracture analgesia guideline, senior geriatrician decision-making and support to community colleagues can reduce in-patient and community opiate prescribing, and stem the growing problem of opioid addiction, misuse and iatrogenic re-admission.
710 IPC STOCKINGS FOR VTE PREVENTION IN STROKE: BENEFITS OF INTRODUCING ELECTRONIC PRESCRIPTIONS AND WARD ROUND PROMPTS
Authors: Ross K , Kattakayam F , Hall E , Barker J R
Published: March 2022

Background

A fully completed audit cycle, performed by doctors on the Stroke Unit at Royal Lancaster Infirmary (RLI) which is a combined acute and rehabilitation ward in a university teaching hospital.

Introduction

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are common complications of hemiplegic stroke. Evidence shows that IPCs (intermittent pneumatic compression devices) reduce the risk of DVT. Recent data from SSNAP reports that IPCs are only used in 33% of all stroke patients. We aimed to improve our local standards in the prescription of IPCs for stroke patients within 3 days of admission, thus reducing the incidence of VTE (venous thromboembolism).

Methods

Data was collected retrospectively from patient records of all stroke patients discharged over a one-month period for each of 2 audit cycles. Prescribing is electronic based at RLI. After the first cycle we initiated a prompt on the electronic VTE pro forma to initiate prescribing. We also changed the prescribing default to regular instead of when required, requiring staff to document when they were not given and the reasons why.

Results

Between the first and second cycle, completion of VTE proformas improved to 100% and VTE incidence reduced from 7.6% to 0. Overall, there was a large improvement in prescribing IPCs within the first 3 days of admission. 71% of patients reviewed in the second cycle had IPCs prescribed compared to 37% in the first.

Conclusion

Adherence to local standards in prescribing of IPCs within 3 days of admission markedly improved after the Introduction of electronic ward round prompts and prescriptions and the incidence of VTE decreased to zero. The prescribing prompts encouraged increased documentation of administering of IPCs. There are still some issues concerning documentation and prescribing of anticoagulants which will be tackled by implementing teaching sessions and updating our electronic prescribing prompts.
712 EVALUATING AN ‘ACUTE FRAILTY TEAM’ MODEL OF CARE IN IMPROVING OUTCOMES FOR PATIENTS WITH FRAILTY ACUTELY ADMITTED TO HOSPITAL
Authors: Thompson J , Gusev V , Dervin P , Tevendale E
Published: March 2022

Introduction

In frailty, Comprehensive geriatric assessment (CGA) has benefit in improving patient outcomes, including hospital readmissions and institutionalisation. We looked to evaluate the effectiveness of our newly initiated multi-disciplinary, acute frailty team (AFT) in improving acute care. This team works on the Acute Medical Unit (AMU), delivering early CGA alongside the existing acute medical care.

Methods

The AFT initially targeted identification of frailty using the Rockwood clinical frailty score (CFS) through local quality improvement work. A standard operating procedure, encompassing CGA for all patients with frailty (define as a CFS 5 to 8 or, 4 with a frailty syndrome) was introduced. This assessment was additional to usual acute medical care. The impact was measured by retrospective case note review of 100 AMU admissions with frailty prior to the team being in post (Jan-March 2020) with a subsequent 100 patients seen by the AFT (March–April 2021). The 2 groups were matched for age, gender, frailty scores and pre-admission residence. These 2 cohorts were compared against key performance indices.

Results

The mean age of patients in the Pre and post AFT cohorts were 85 years and 84 years respectively with an average CFS of 6. The identification and documentation of frailty improved in the AFT intervention cohort from 31% to 100% and screening for delirium with 4AT improved from 27% to 91%. The number of patients in the AFT cohort discharged directly from AMU increased from 5% to 14% with the average length of in-patient stay reducing from 10.2 days to 7.8 days. Thirty day remission fell from 23% to 16% in the AFT cohort, and the number of patients discharge to new 24 hour care declined from 21% to 9%.

Conclusion

Our AFT alongside existing acute medical care improved outcomes including, frailty identification, delirium screening, length of stay, re-admissions and institutionalisation.
713 COLLABORATION WITH CARE HOMES TO PROVIDE APPROPRIATE MEDICAL CARE IN THE PANDEMIC
Authors: Kelly S , Griffiths B , Davies A , Adenwalla F
Published: March 2022

Background

The Acute Clinical Team (ACT) in Neath Port Talbot is a well-established hospital at home service that provides treatments in the community. During the COVID 19 outbreaks, the team proactively telephoned the care home managers on a regular basis to enquire about the residents wellbeing and establish if input was required. This proactive approach worked well with some homes. Where crises developed, we were able to provide hands on support to provide appropriate medical care.

Methods

A collaborative effort from community teams and volunteers assisted ACT to provide nursing and medical interventions in care homes which accepted our help. Interventions included intravenous (IV) antibiotics, parenteral fluids, IV/oral dexamethasone, low molecular weight heparin, oxygen (up to 10 L face mask), communication with families and palliative care.

Results

Data is presented from 7 care homes for which ACT provided input; patients who were unwell requiring additional help were referred to the team. Comparative data from a care home in the same area where ACT was not involved is presented. Data was collected from 01/11/20-10/02/21. Table 1 Care homes with ACT involvement (190 patients) Care home without ACT involvement (85 patients) Patients assessed Patients not assessed No. with COVID-19 infection (%) 96/190 (51%) 94/190 (49%) 27/85 (32%) Acute hospital admission related to COVID-19 (%) 3/96 (3%) 7/94 (9%) 8/27 (30%) Died within 28 days of positive test(%) 37/96 (39%) 20/94 (21%) 15/27 (56%).

Conclusion

ACT had a vital role during the outbreak in supporting the local community. The team was able to provide a range of interventions and prevent avoidable admissions. The team received excellent feedback ‘We couldn’t have survived without the ACT teams input. They were our lifesavers. The whole team were amazing and came to our rescue where everyone else who knew we had COVID bolted to the hills’ Manager.
716 A MULTIDISCIPLINARY SIMULATED TEACHING PROGRAMME ON TREATMENT ESCALATION PLANNING IN THE CONTEXT OF FRAILTY
Authors: Corson C , Fair K
Published: March 2022

Introduction

We designed a simulated teaching session to enable participants to learn more about Treatment Escalation Planning (TEP) and do not attempt resuscitation (DNACPR) orders in the context of frailty and to simulate communication of these decisions with the patient/relative.

Method

We designed a teaching session which started with discussion of the participants individual learning Objectives. The session involved group discussion surrounding frailty and ways to assess it, communication skills and tools and TEP/DNACPR. We also discussed specific communication issues during the pandemic. The session then moved onto simulated conversations with a patient/their relative using the skills just discussed. Every participant had the chance to complete the scenario. Each participant also had a ‘debrief’ lead by the authors and valued input from a Resuscitation Officer. To date, 5 sessions have been completed with 13 participants. Participants were medical doctors, advanced nurse practitioners and acute care of the elderly practitioners.

Results

The mean overall rating of the session was 9.4/10. Participants recorded confidence scores in 4 main areas pre and post session. We found that, by participating in the session, confidence improved in all 4 areas; confidence assessing level of frailty, how to agree TEP decisions, initiating conversations around TEP, discussing potential treatment options with patients/relatives.

Conclusion

We have developed a simulated teaching session, which has been rated highly and is shown to be effective in increasing the confidence of participants when discussing TEP in the context of frailty. Our next steps will be to expand the programme to deliver further sessions.
737 STOOLS FOR STOOLS - COMBINING MEDICAL AND CONSERVATIVE TREATMENTS TO REDUCE CONSTIPATION IN THE ELDERLY INPATIENT POPULATION
Authors: Roth N , Khalil N , Moore-Gillon C , James D , Gilby L , Morgan C
Published: March 2022

Introduction

Constipation is a common cause of morbidity in the elderly. Its management is particularly challenging in the inpatient population, where many factors exacerbate constipation. We describe a Quality Improvement Project to reduce the rates of constipation on a female Medicine for the Elderly ward.

Aims

Our aim was to increase bowel chart documentation (nursing and doctor entries) and increase patient frequency of bowel motions to at least once every two days. In particular we focused on conservative measures such as the use of footstools to optimise posture when using commodes and toilets [R Hari Krishnan, Proc Inst Mech Eng H, 2019, 233(4):464–475].

Method

• Weekly monitoring of ward inpatients. • Measurements taken were: days since last bowel motion, laxatives prescribed, bowel chart and ward round documentation, and episodes of diarrhoea over the past week. • One episode of diarrhoea was defined as 3 motions of type 6 or type 7 stool in 24 hours. • A new intervention was introduced every two weeks, over a total of 2 months. Interventions: 1. Recording bowel motions at the daily ‘Board Round’ Multi-Disciplinary Meeting. 2. Ward staff education sessions. 3. Footstools for use with commodes and toilets. 4. High-fibre foods to patients with constipation.

Results

Level of constipation was successfully reduced, with 100% patients moving bowels every 2 days from a baseline of 68%. Ward round and bowel chart documentation improved to 100% and 93.3% respectively (from 41.3% and 33.3%). However, incidence of diarrhoea increased from 0 episodes/week to 8 episodes/week, with laxative prescriptions similarly increased from 50% to 86%.

Conclusion

Constipation improved with our interventions, but at the unintended cost of laxative-associated diarrhoea. Our next steps will be to reduce laxative prescriptions in favour of conservative measures, in order to reduce episodes of loose stool while maintaining our improved constipation rates.
744 3 YEAR FOLLOW-UP OF SEDATIVE PRESCRIBING FOR RESPONSIVE BEHAVIOURS IN NURSING HOME RESIDENTS, AN IRISH STUDY
Authors: Killeen E , Horan S , Pollock A , Lee A , Martin A
Published: March 2022

Introduction

Sedative medications are commonly prescribed for older adults; these include neuroleptics, benzodiazepines, opioids, ‘z’ drugs and trazadone. The prevalence of sedative drug prescriptions is increasing (1). Nursing home residents are three times more likely to be prescribed benzodiazepines (2). Regular medication review and education have been shown to reduce rates of sedative use in nursing homes (3). We previously demonstrated a significant reduction in prescription of these target medications at an Irish nursing home with specific focus, within scheduled medication reviews, on reduction or discontinuation of the target drugs in combination with education on management of Behavioural and Psychological symptoms (BPSD). This audit examines the prescribing patterns 3 years on from the initial audit.

Methods

Point prevalence study of sedative prescriptions and BPSD of all 95 nursing home residents on 6/5/21. Comparison with data from two previous audits in the same unit. All data was anonymised. Data analysed with SPSS statistical software.

Results

Sustained significant drop in quetiapine use from 30% of residents to 14% post-intervention in 2018 and three-year follow-up (p = 0.06). Borderline significant reduction in overall neuroleptics (from 39% to 25%, p = 0.06). Significant rise in ‘z’ drug prescription (from 8% to 17%, p = 0.03). BPSD reported in 33%, compared to 49% pre-intervention.

Conclusion

Regularly scheduled medication reviews can effectively rationalise sedative prescription rates in nursing home residents. Increasing ‘z’ drug prescription likely represents the appropriate replacement of neuroleptics. Reduced BPSD may be due to reporting bias of staff since regular education has been introduced or changing cohort of residents. References numbered above not included given limited word count.
756 ORTHOPAEDIC SURGEONS CAN PRESCRIBE LAXATIVES & ANALGESICS TOO - A QUALITY IMPROVEMENT PROJECT SPANNING 7 YEARS
Authors: Kim K K B , Gibson P
Published: March 2022

Background

Patients admitted with age 60 years and over with a hip fracture admitted to a District General Hospital.

Introduction

The aim was to improve the prescribing of regular laxatives and analgesia at the time of admission to hospital.

Methods

There were repeated PDSA cycles. Data was collected on consecutive patients (by admission date) identified from the National Hip Fracture Database. Data was collected at baseline (10 patients in November 2013) and after Phase 1 intervention (20 patients, December 2013—January 2014), after Phase 2 (20 patients, February 2014), after Phase 3 (39 patients, April—June 2017) and after Phase 4 (September—October 2020). The interventions were as follows: Phase 1: Prompts at new doctor induction (‘Induction’) + prompts in hip fracture admission document. Phase2: Phase 1 intervention + flow diagram in fracture admission document. Phase 3: Prompts at Induction + electronic prescribing protocol (including laxatives and analgesics) + removal of flow diagram from admission document. Phase 4: Phase 3 intervention + more effort to explain to new locum doctors.

Results

Laxative prescribing: Baseline = 40%, Phase 1 = 80%, Phase 2 = 80%, Phase 3 = 56%, Phase 4 = 74% (24 hours post-admission = 90%). Paracetamol prescribing: Baseline 100%, Phase 1,100%, Phase 2,100%, Phase 3 64%, Phase 4 82% (24 h post-admission = 90%). Regular strong opioid prescribing: Admission: Baseline 60%, Phase 1 90%, Phase 2,100%, Phase 3 44%, Phase 4 80% (24 h post-admission = 90%).

Conclusion

1. Orthopaedic Surgeons can prescribe laxatives and analgesia well—given sufficient prompts 2. The electronic solution is not always sufficient—locum doctors may not be aware of it. 3. Do not assume continued success Future Plans Re-introduce flow diagram to admission document. Acknowledgements Many people have helped with previous phases & will be acknowledged.
757 ASSESSING THE READMISSION RATES OF THE OLDER PERSON’S ASSESSMENT AND LIAISON ACUTE FRAILTY TEAM AT GOOD HOPE HOSPITAL
Authors: Brice H G T , Sheikh S , Quigley T
Published: March 2022

Introduction

The Older Person’s Assessment and Liaison (OPAL) team at Good Hope Hospital (GHH), part of the University Hospitals Birmingham NHS Foundation Trust, provides multidisciplinary, patient-centred comprehensive assessment to patients presenting to the hospital front door. The team takes a ‘home first’ approach and where possible aims to discharge patients home with support by community teams. The service is part of the Birmingham wide Early Intervention programme. A front door OPAL service therefore enables early discharge for frail patients who would otherwise be likely to have a prolonged hospital admission. This has to be balanced against ensuring readmission rates do not exceed that of a comparable hospital inpatient population.

Method

We measured the 7 and 28-day readmission rate of all patients who received OPAL input and were discharged from A&E, the Medical Admissions Unit or the Acute Medical unit from July 2020—January 2021. This was compared with an inpatient short stay frailty unit however data was not available beyond November 2020 due to changes in response to the Covid-19 pandemic.

Results

2096 patients were discharged by OPAL with a 7-day readmission rate of 9.2% (95% CI 4.6–13.7%) and a 28-day readmission rate of 20.2% (95% CI 14.0–26.4%). From July—October 2020 the short stay frailty unit at GHH had a 7-day readmission rate of 9.7% (95% CI 3.1–16.3%) and a 28-day readmission rate of 25.2% (95% CI 8.2–42.2%). In the same period OPAL had a 7-day readmission rate of 8.7% (95% CI 3.2–14.2%) and a 28-day readmission rate of 19.9% (95% CI 13.3–26.5%).

Conclusion

The OPAL service enabled the early discharge of patients without compromising readmission rates. The readmission rates for patients discharged by the OPAL team were better than the inpatient frailty unit with over 20% fewer 28 day readmissions.
781 IMPROVING THE QUALITY OF DO NOT ATTEMPT CARDIO-PULMONARY RESUSCITATION (DNACPR) FORM COMPLETION
Authors: Rasquinha M , Ng K , Hillarious A , Pugh L , Ghobrial H , Emuss D , Shiel K , Vettasseri M
Published: March 2022

Introduction

The completion of a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) form represents an important part of patient care. However, this can be a sensitive process that has gained national media interest. The aim of this Quality Improvement (QI) Project was to improve the quality of DNACPR form completion in a Care of the Elderly Department.

Methods

The QI project ran from May 2019 to January 2021 and was overseen by a multi-disciplinary team (including patient representation). DNACPR forms on the Care of the Elderly wards were audited monthly against 7 standards which correspond to key sections on the DNACPR form. During the data collection process, interventions were implemented using Plan-Do-Study-Act cycles. Interventions included: appointing ‘DNACPR Champions’ to complete monthly audits and provide personalised clinician feedback, the introduction of a new mandatory e-learning module, the creation of an alert system on nerve centre (the Trust’s electronic handover system) and the development of new DNACPR patient information including webpage development, videos and leaflets.

Results

The project has led to sustained improvements in majority of the 7 standards. The biggest improvements were seen in the inclusion of a review date, correct completion of the mental capacity assessment and the use of patient information leaflets. The documentation of discussions with patient and relatives remained below the audit standards and was largely unchanged during the QI project.

Conclusion

A multi-disciplinary and multi-faceted QI approach has shown to improve the quality of DNACPR form completion. Further work is needed to continue this process and a focus on staff training and ward-level processes will be the priority.
787 THE PRUNE PROJECT: USING PRUNES AS A CONSTIPATION AID IN OLDER SURGICAL INPATIENTS
Authors: Coath F , Morgan C
Published: March 2022

Introduction

Constipation is a common and difficult issue in elderly surgical patients, often contributing to prolonged stay on inpatient wards (Sethi et al, Am J Gastroenterol. 2014;109:250–256). Increasing dietary fibre is a commonsense tactic to mitigate against constipation. However it is rarely formally employed on NHS wards. Prunes are beneficial in increasing fibre intake and are a natural source of sorbitol, which acts as an osmotic laxative (Stacewicz-Sapuntzakis et al, Crit Rev Food Sci Nutr. 2001;41:251–86.)

Method

We performed a closed-loop audit on the use of prunes in reducing constipation. We collected data from surgical inpatients over 60 years, including the number of days since bowels were last opened, and the number of laxatives that each patient was taking. Patients were then given a prune product (either 3 dried prunes, 125 mL prune juice or 70 g prune puree) three times a week. Following the intervention, the data was recollected to complete the audit cycle.

Results

In our cohort of 36 patients, the mean time since bowels were last opened reduced from 1.49 to 1.17 days (p = 0.1624) after introducing prunes three times a week, and the mean number of laxatives reduced from 1.81 to 1.50 (p = 0.1671).

Conclusion

Surgical patients are at increased risk of constipation (Davies et al, J Clin Pharm Ther. 2008; 31:561–566) due to multiple factors including immobility, poor oral intake and opiate use. Constipation is more common in the elderly (Talley et al, Am J Gastroenterol. 1996;91:19–25), who are also at increased risk of polypharmacy (Morin et al, Clin Epidemiol. 2018;10:289–298). These results show that using prunes to aid regular bowel motion can have a positive impact on reducing pharmacy and increasing frequency of bowels opening. We hope that, by introducing tactics to promote regular bowel motions in hospital, we can reduce polypharmacy and instill good health habits post-discharge.
793 COLLATERAL HISTORY IN PATIENTS WITH CONFUSION
Authors: Georgiou K , Mock J , Peter E
Published: March 2022

Introduction

The aims of the project were to intervene early on admission, by taking a collateral history for patients with confusion; to improve the quality and detail of collateral history being taken to better establish certain clinically important specks of information. These include triggers for delirium, the patient’s baseline cognition, any patterns in the change of a patient’s cognition to help determine if a patient was displaying aspects of a certain type of dementia prior to admission, baseline mobility and housing situation, baseline continence, history of substance misuse and alcohol etc. Ultimately, this project aims to identify next of kin from which collateral history can be obtained, but also to establish a firm communication platform to facilitate future discussions on behalf of patients undergoing delirium. This will ultimately, improve care but also making sure family members are involved early on in admission, exploring their ideas, concerns, and expectations.

Methods

We created a collateral history template booklet that was introduced to a geriatric ward. Specific parameters were set and measured, pre-intervention and post-intervention. A second round of post-intervention data collection was performed with an improved collateral history sheet outlook. We measured the outcome of 22 collateral histories for each round.

Results

We found that in both rounds, post intervention, there was an improved outcome compared to pre-intervention in almost all the parameters that were measured. For example, in 100% of the collateral histories there was documentation of the patient’s baseline concentrations and attention, issues with orientation, issues with expressive and receptive dysphasia and the main concerns of the next of kin, any problems with executive functioning and the baseline functional status of the patients.

Conclusion

The collateral history, both improved the overall quality and the quantity of the information gathered in patients with confusion and, contributed to a structured management.
796 THE IMPORTANCE OF CHEST X RAYS AS AN INITIAL INVESTIGATION IN ROUTINE ACUTE ELDERLY CARE ADMISSIONS
Authors: Tantoush M , Menon V , Ahmed N
Published: March 2022

Introduction

The Chest X-Ray (CXR) is a common and central initial investigation for any patient that has been admitted via Accident and Emergency (A&E). In the context of elderly care, it is a useful measure of a patient’s baseline functional status as well as a tool for cancer surveillance and other aspects of clinical care. Accurate documentation of CXR review is also imperative for closed loop communication of clinical information amongst a multi-disciplinary team.

Methods

Twenty-eight random inpatients in a local NHS Trust Healthcare of Older People (HCOP) department were selected to be part of this two-cycle study. Using hospital database records, the CARESTREAM imaging system and patient clinical documentation, data including the following was collected: whether a CXR was completed, was CXR review documented in patient notes and initial reason for admission. As per local practice, all acute HCOP admissions should undergo a CXR and have an image review clearly documented in patients’ clinical noting. The established target was 95% compliance for both. Following intervention by way of ward poaters and presentation at a local quality improvement meeting the cycle was repeated to ascertain improvement in compliance.

Results

22 (79%) HCOP patients had a CXR on admission. Of those completed CXRs, only 6 (27%) of these showed evidence of review (documentation in clinical noting). Following the above mentioned interventions, 25 (89%) of HCOP patients had a CXR on admission, showing an improvement. Of those completed CXRs, 20 (80%) showed evidence of documented clinical review– once again showing improvement.

Conclusions

CXRs and their accurate documentation is an important aspect of the holistic care of the HCOP patient. Ensuring that compliance for completing the scan and documenting results should be a priority in clinical quality and safety. Our interventions have shown an improvement in compliance and resulted in sustainable change.
798 SPOT DELIRIUM - IMPROVING DELIRIUM AWARENESS AND ASSESSMENT USING ELECTRONIC 4AT
Authors: Kotecha S , Dennis L M
Published: March 2022

Introduction

Delirium is a common medical emergency which is associated with adverse outcomes but often unrecognised in up to two thirds of patients in the acute care setting. The 4AT is a sensitive and rapid assessment tool that can be applied to assess for delirium in clinical practice.

Method

An initial audit into the use of delirium diagnostic assessment scores on an Acute Medical Assessment Unit (AAU) was carried out. Medical notes were reviewed of patients over 75 years (n = 42) admitted over a 6 week period. A re-audit was undertaken following an educational induction session for junior doctors about delirium and 4AT (n = 42).

Results

Initially 14% of patients with documented acute confusion (n = 2) had a 4AT assessment completed. 2 patients were recognised to be at risk of delirium but did not have a 4AT. A diagnosis of dementia was documented for 28% (n = 12) of patients however only one had a 4AT. An educational session about delirium and how to complete the electronic 4AT assessment was organised for junior doctors on AAU. Before teaching, survey results showed no participants were familiar with the 4AT screening tool. Following the session all participants indicated knowing where to locate the electronic 4AT and reported improved confidence in recognising delirium. On re-audit 14 patients had documented confusion but 4AT assessment completion increased to 79%. For those identified as being at risk of delirium or having previous delirium 90% had a 4AT completed. All patients with a dementia had an AMTS and 89% also had a 4AT.

Conclusion

There was an improvement in documentation of both 4AT and AMTS forms following engagement in education and use of an electronic assessment tool to diagnose delirium. Future recommendations include interdisciplinary induction sessions to target a wider audience to improve awareness and recognition of delirium in acute care.
816 COORDINATE MY CARE: INCREASING STAFF ACCESS AND NUMBER OF PATIENT RECORDS CREATED IN A BUSY ACUTE HOSPITAL - A QI PROJECT
Authors: King C , Arumugam J , Bichard J
Published: March 2022

Introduction

The Royal College of Physicians have emphasised the need to provide good end of life care for patients in the acute care setting, with the publication of the Acute Care Resource (1) in February 2021. This follows on from their key recommendations in 2018, which proposed that ‘all healthcare professionals reviewing patients with chronic conditions,…more than one serious medical problem, or terminal illness, should initiate shared decision making including advance care planning in line with patient preferences’ (2). Coordinate My Care (CMC) is an electronic urgent care plan accessible to all relevant health and social care professionals caring for patients residing in London Boroughs, enabling communication of wishes and preferences, including those of resuscitation status and advance care plans.

Method

Multiple PDSA Cycles, including requesting logins for CMC for emergency medicine, acute and general medical senior and junior doctors, and hosting CMC training sessions. Teaching sessions given to the above cohorts with regard to advance care planning and the use of CMC. Creation of live link to CMC via Trust’s electronic patient record.

Results

An increase in average monthly CMC record views from 45 to 108 by clinicians at North Middlesex Hospital. An increase from an average of 18 CMC records created per month, compared to 27 records created per month after the QI project, with an estimated additional cost saving of almost £19,000 per month (3).

Conclusion

Successful QI project, with demonstrated increase in staff access to CMC and number of patient CMC records created in a busy acute hospital. Ongoing success will be reflected in sustainability of the current numbers of acute hospital staff accessing CMC and creation of records.
661 PROGNOSTIC FACTORS OF DEPRESSION AFTER HIP FRACTURE SURGERY: SYSTEMATIC REVIEW
Authors: Milton-Cole R , Ayis S , Lambe K , O’Connell M D L , Sackley C , Sheehan K J
Published: March 2022

Introduction

Patients with hip fracture and depression are less likely to recover. This review aimed to identify prognostic factors of depression up to one year after hip fracture surgery in adults. Secondary aims were to determine whether identified factors are modifiable or non-modifiable and describe proposed underlying mechanisms for their association with depression.

Methods

We searched MEDLINE, Embase, PsychInfo, CINAHL and Web of Science Core Collection databases for published studies as well as grey literature. We did not impose any date, geographical, or language limitations. Two reviewers independently screened studies against predefined eligibility criteria to identify relevant papers. We included observational studies investigating prognostic factors of depression up to one year after surgery in adults surgically managed for non-pathological hip fracture. Two reviewers independently extracted data (Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies, adapted for use with prognostic factors studies Checklist) and completed quality appraisal (using Quality in Prognosis Studies tool).

Results

3,402 studies were identified; 2,915 studies were excluded leaving 13 studies included in this review. 3,769 patients were included across all studies with a mean age ranging from 76.21–81.82 years. A total of 39 prognostic factors were investigated and most studies failed to identify a primary prognostic factor of interest. Most of these factors were patient factors with only a few being process or structure factors.

Conclusion

Various potential prognostic factors of depression after hip fracture were identified however, Methodological quality and heterogeneity between studies limited the certainty of which prognostic factors were the strongest. High-quality research investigating prognostic factors using the same study design, Methodology and measurements is warranted to allow for comparisons of the predictive power of factors. As well as future research into the underlying mechanisms of prognostic factors.
683 UNDERSTANDING HOW DISCHARGE SERVICES FOR OLDER PATIENTS CAN BRIDGE THE GAP BETWEEN HOSPITAL, COMMUNITY AND SOCIAL CARE
Authors: O’Connell Francischetto E , Jones J , Allen K , Combes G , Damery S
Published: March 2022

Introduction

UK policy recommends that discharge support is provided by hospital, community and social care staff. However, there is a lack of understanding regarding how these multiagency hospital discharge services work in practice, how they can be sustained and what service stakeholder experiences of them are. This research aimed to understand how integrated discharge services work and the views and experiences of stakeholders.

Method

A qualitative case study of a supported integrated hospital discharge service (SIHDS) for older people was undertaken, which involved interviews with service staff (hospital, community and social care), patients and carers. Staff, patients and carers were interviewed on their experiences of SIHDS. Staff also took part in a process mapping exercise to understand how the service works. Interviews were analysed using thematic analysis. Ethical approval was obtained for this research.

Results

A variety of staff (n = 14) and patients aged over 60 years (n = 11) and their informal carers/family members (n = 4) were interviewed. Three main staff themes emerged from the findings: 1. Preparedness for discharge and impact of discharge service; 2. Integration and impact on patient pathway and 3. Organisational aspects. The three main patient/carer themes were: 1. Support for patients; 2. Patient Outcomes and 3. Information exchange. The findings demonstrated that: SIHDS was seen as important to allow patients to be discharged home in a timely and safe manner; that communication is important at all levels of a SIHDS and SIHDS need to continuously evolve to provide patient centred care.

Conclusion

The findings from this qualitative case study allow the complexities involved in SIHDS to be understood from the experiences and perspectives of multiagency staff, patients and carers. It shows SIHDS are complex, but useful to overcome gaps between services. However, to effectively sustain a patient centred service it is important to regularly review and develop SIHDS.
734 ACUTE CARE PATHWAYS FOR OLDER MAJOR TRAUMA PATIENTS: A SURVEY OF UK PRACTICE
Authors: Jarman H , Cole E , Crouch R , Halter M , Peck G
Published: March 2022

Introduction

Major trauma is a significant health burden for older patients, with worse clinical outcomes when compared to younger people. Various clinical models exist however it is not clear which have most benefit for older patients. This study aimed to map the current provision of clinical pathways and services for older people with major trauma in the United Kingdom (UK).

Methods

A cross-sectional online survey was undertaken. Case vignettes designed to reflect ‘typical’ older major trauma patients were embedded within the survey. The survey was distributed via trauma network managers and social media, inviting responses from all UK hospitals receiving trauma patients in 2020. Fixed choice questions were analysed with descriptive statistics and free text responses categorised into themes. The survey was not deemed to be research using the UK Health Regulatory Authority tool.

Results

Responses were received from 20/27 Major Trauma Centres (MTCs), 33 Trauma Units (TUs) and two local emergency hospitals. Older patients were defined by age (range 55 to 82 years) or frailty status. Frailty assessment was routinely performed in more than two-thirds (69.1%) of locations. Availability of trauma-specific guidance for older patients varied, and was greater in TUs than MTCs. Analysis of the vignettes showed wide variability in the admission and subsequent interventions for older major trauma patients across hospitals. Qualitative data showed pre-injury health status, staff availability, and day of the week were factors leading to variation within individual hospitals.

Conclusion

There is wide variation in the processes of care and pathways for older major trauma patients in the UK. Whilst lack of standardisation may be a result of local service configuration this has the potential to impact negatively on quality of care, multi-disciplinary working and outcomes. Understanding the range of variation in practice provides opportunity to identify good practice and areas for improvement.
809 USE OF NEW MOBILITY SCORE AND A TRANS-DISCIPLINARY APPROACH TO REDUCE HOSPITAL LOS, RETURN TO ORIGINAL RESIDENCE, AND MORTALITY
Authors: Leong D , Ng P , Brien A , Law K , Potter C , Sampson S , De Silva S
Published: March 2022

Introduction

The National Hip Fracture Database indicated Guy’s and St Thomas’ Trust ranked in the fourth quartile nationally with reference to hospital length of stay (LOS), return to original residence (ROR), and mortality in hip fracture patients in 2018. This quality improvement project aimed to improve and maintain these key factors via a two-stage process.

Methods

Stage one involved implementation of four key interventions through a trans-disciplinary focus group, comprising ortho-geriatricians, orthopaedic surgeons, physiotherapists (PT), occupational therapists (OT), nursing staff, and a transfer of care navigator (TCN). Firstly, the New Mobility Score (NMS) was employed as a tool to guide estimated length of stay. Secondly, use of preoperative OT assessment allowed early evaluation of patient expectations concerning discharge planning. Third, facilitation of the discharge process was optimised by the recruitment of a TCN. Lastly, attendance of a senior orthogeriatrician during the daily board round was established. Stage two involved education of new members of the trans-disciplinary team to ensure that the key interventions listed above were maintained on hip fracture patients.

Results

Following stage one, average acute hospital LOS and overall LOS decreased from 20.1 to 15.1 days and 22.4 to 18.3 days, respectively. Rate of ROR within 120 days of discharge improved from 72.4% to 86.9%, while mortality rates fell from 7.1 to 3.4. Following stage two, overall LOS improved to 17.1 days, while acute LOS and mortality were maintained at 15.6 and 3.9 days, respectively. While ROR fell to 82.8%, this remained higher than the national average at 69.9%.

Conclusions

Utilisation of NMS and multi-disciplinary input effectively improved ROR, while reducing length of hospital stay and mortality rates in hip fracture patients. Education of new members of the trans-disciplinary team allowed sustained improvement despite challenges faced during the COVID-19 pandemic.