bluuebunny/crossref_metadata_2025 huggingface dataset:
33 Improving Mortality with An Integrated Model of Care for Cervical Spine Fracture in Patients Over 75 Years Old
Authors: Mahmood R , Negasan C , Manzoor A , Enwere P , Arnada-Martinez A , Walters H , Yeong K , Lisk R
Published: February 2020

Introduction

Cervical spine injury is a potentially life threatening trauma. Given the increase in the number of patients presenting to the emergency department (ED) who are elderly and who have fallen and sustained trauma, it has become ever so challenging to manage this cohort of patients. In addition to diagnostic challenges in the elderly population, a robust, integrated care pathway and comprehensive geriatric assessment with involvement of a geriatrician is essential to provide effective care to these patients who require cervical collar after cervical spine injury to prevent morbidity and mortality.

Intervention

Data was gathered about the patient’s demographics, nature of cervical spine injury, care required from January 2013 till November 2016 (pre intervention) and from November 2016 till October 2017 (post intervention). Current practice was reviewed which showed significant variability in care provision to patients with cervical spine injury including collar care.

An integrated care pathway was designed with involvement of multidisciplinary team (MDT) members to standardise the care of this cohort of patients in our hospital. This included early identification of patients with cervical spine injury, co locating all patients, developing nursing expertise for cervical collar care, sitting up early to prevent complications like aspiration, pressure area care, early nutritional support, training staff in post discharge collar care with developing interface with primary care team. Outcome measures in patients over 75 years including length of stay (LOS) inpatient mortality and at 6 and 12 months were recorded respectively.

Results

Total: 54 patients, average age: 86.6 years

Conclusions

Cervical spine injuries are common in older patients, who are at greater risk of falls and thus sustaining injuries. Early identification and management of these patients in a clinical area with multidisciplinary approach with appropriate expertise is key to reducing LOS and adverse outcome including mortality.
34 Geriatricians in Intermediate Care Settings: A Modern Approach to Geriatric Medicine
Authors: Enwere P , Mahmood R , Aranda-Martinez A , Manzoor A , Wilkinson E , Soliman K , Yeong K , Lawn L , Lisk R
Published: February 2020

Introduction

Due to growing older population with increasing medical complexity and care needs, over-reliance on acute hospitals for care delivery, disconnect between social and medicalised care and challenging national health services (NHS) financial climate, it is essential to provide much of this care to our older patients outside the acute hospital before they reach crisis point. This prevents unnecessary hospital admissions and outpatient referrals especially to our geriatric services. Therefore, newer and innovative care models are required to cater the needs of our aging population especially within the community settings. The North West Surrey clinical commissioning group (CCG) catchment area is divided into three localities, namely SASSE Locality in Spelthorne, Thames Medical Locality in Runnymede/West Elmbridge, and the Woking Locality (Bedser hub) in Woking.

Locality hub model of integrated care led by GP with multidisciplinary (MDT) input along with wellbeing coordinators was introduced to address above issue.

Objectives

Our mission was to find a way to manage the challenges we face from a growing older population within an integrated GP-led community service and in a manner that promotes independence, reduce social isolation, improve patient experience and safely deliver appropriate acute care in the community whilst reducing dependency on regional acute hospitals. A fully qualified geriatrician input was introduced within the hub model at Bedser hub.

Results

Total savings: £16,484, Geriatricians input cost: £16,500 Cost neutral intervention

Conclusions

Newer models of collaborative healthcare within the community dwellings with GP and geriatrician input along with multidisciplinary approach are essential to deliver safe and high quality care to our older population, thus reducing reliance on our ever so stretched local acute NHS hospitals.

Our intervention has resulted in reduction of referrals to geriatric outpatient clinic and enabled us to provide the required care to our older population closer to home. It has also led GPs to build their skills in managing the very frail patients with complex needs safely and effectively. In the long run, the intervention will be cost effective with further projected reduction in referrals.
35 Enhanced Service Through An Integrated New Model of Care in A Buckinghamshire Care Home
Authors: Okoli U , Chimhau S , Nagyova B , Sahni A , Amin S , McGarry S
Published: February 2020

Introduction

Care home residents often have multiple, chronic conditions and are receiving complex treatment regimes. Polypharmacy and medication errors are common. The frequency and quality of medication reviews is variable with limited general practice (GP) capacity to carry out comprehensive reviews.

The initiative used a care home pharmacist, technician, geriatrician and GPs to tackle these issues on an individual and care home level. The objective being to ensure the safe and effective use of medicines for all care home residents. NICE guideline [NG56] recommends reducing pharmacological treatment burden for adults with multimorbidity at risk of adverse drug events such as unplanned hospital admissions. A study by Dilles et al1 found adverse drug reactions in 60% of residents.

Methods

A new interdisciplinary model of care was delivered in a 120 bedded Buckinghamshire care home. Clinical Commissioning Group pharmacist, general practitioners and pharmacy technician reviewed medication for all residents. The most complex individuals were reviewed by the geriatrician and if needed by other multidisciplinary team members specialist.

Results

Overall 115 medications were stopped for 109 residents, with 31 interventions to reduce falls risk and 19 interventions on medication at high risk2 of causing admission. Total cost savings on medicines optimisation, medicines waste and non-elective admission prevented was £35,211. Residents’ care plans were updated to reflect best practice standards.

Conclusions

Future direction of this project focuses on system wide improvements to promote interdisciplinary healthcare professionals work in care homes. The success of this integrated model of care has enabled recurrent funding of pharmacist by the local county council and an additional 42 geriatrician sessions into Buckinghamshire care homes.

References

1. Dilles T, Vander Stichele R, Van Bortel L, Elseviers M. Journal of American Medical Directors Association 2013; 14: 371–6.

2. Pirmohamed M, et al. Br Med J 2004; 329: 15–9 61.
37 Enhance GP-Geriatrician Care Homes Multidisciplinary Team
Authors: Ruiz-Mendoza E , Penart A , Obi I , Addison E , Clark H
Published: February 2020

Introduction

Peterborough Care Home Support Team (CHST) have worked on a small pilot of 4 care homes with a local GP and an interface geriatrician to address the complex needs of the residents within those care homes to improve patient experience, quality of care and reduce attendances and admissions to hospital in a geographical area of 5000 care home beds.

Methods

The multidisciplinary team (MDT) consisted of a General Practitioner, Interface Geriatrician, Pharmacist from the medicine optimisation team and Care Home Support Team member with once a month meeting in the selected Care Home. We measure the impact of our intervention comparing the data predating our intervention comparing 4 selected care homes with high A&E attendances in each period 2017 and 2018.

Results

50% reduction in hospital attendances with £4985.48 cost saving following medication review in the 4 care homes under study.

Conclusions

Commissioners, Local Authorities and Care Home Providers have started to look towards more innovative solutions to improve patient experience, quality of care and reduce attendances and admissions to hospital. Our experience and results aim to consider enhance GP-Geriatrician Care Homes MDT as a good model of care.
43 A Model of Interdisciplinary Working to Enhance the Care of Residential Home Patients
Authors: Goodwin E , Bacarese-Hamilton T , Steel A , Patel A
Published: February 2020

Introduction

291,000 patients in the UK live within the care home setting. The King’s Fund reports that the average residential home patient is an 85-year-old female with a 12-30 month life expectancy. Care needs are complex with six or more diagnosed conditions, seven or more prescribed medications and a combination of physical frailty, disability and mental health conditions. In line with the NHS Long Term plan 2019 the Care Home project sought to promote ageing well through interdisciplinary working.

Aims

Provide cost neutral interdisciplinary review of care home residents Review the medication of all residents Review resuscitation status and initiate anticipatory care plans for appropriate residents To further the education and professional relationships across primary, secondary and mental health interface. Reduction of transitions between care settings for residents.

Methods

12 sessions in 1 care home over a year (2018-2019) Team consisted of GPs, Geriatric Registrars, Old Age Psychiatry Registrar, care home staff and CCG pharmacist 2-4 patients per session chosen on the basis of complex physical and/or psychological needs Format of session consisted of: o Pre-assessment discussion of patient o Interdisciplinary patient review o Debriefing and formulation of management plan Sessions concluded with teaching from the different disciplines.

Results

We reviewed 25 residents with an average Clinical Frailty Scale score of 7. 100% patients had a medication and psychiatric review. 100% had review of DNAR status with 40% increase in DNAR forms completed. There was a 60% increase in anticipatory care plans initiated. There was a reduction in acute admissions from the care home with a resultant cost saving of over £45,000. 100% of participants would strongly recommend the project and reported improved relationships. 90% of care home staff thought the project was beneficial to the residents and staff felt more supported.

Conclusions

Interdisciplinary working within the patient’s own setting provides patient centred care, promotes sharing of professional expertise, enhances clinical skills and builds professional relationships. This model of project is easily scalable and is a cost-effective way of providing high quality care for patients in their own residence.
46 The Accuracy of Frailty Scoring and Uptake of Comprehensive Geriatric Assessment (CGA) In Patients Living with Frailty Admitted Through the Emergency Department (ED) In Wythenshawe Hospital
Authors: Murphy A , Briggs S
Published: February 2020

Introduction

Frailty can be defined as a state of physiological decline related to ageing and its identification is crucial for subsequent management. A Cochrane review found that CGA significantly reduces mortality and institutionalisation at 6 months.1 Published standards for the hospital state that patients with a clinical frailty score (CFS) of ≥7 should be seen by a geriatrician within one hour of presentation to hospital. We investigated if this was met.

Methods

Assigning a CFS to all patients ≥65 was introduced to ED triage in November 2018. Patients scored as ≥4 were identified over a 10-day period. We assessed the accuracy of ED based frailty scoring, subsequent hospital wide CGA uptake and investigated if patient’s frailty scores influenced this. We also compared CGA uptake across specialities.

Results

Over 10 days, 230 patients entering ED were identified as frail. 33% of patients received CGA. On average, it took 18 hours for a patient to get CGA, and 23 hours for a patient with a CFS ≥7 to receive CGA from a geriatrician. The CFS had no influence on them receiving CGA. Surgical specialities were better than some medical specialities in assessing frailty. 38% of the patient’s CFS were correct.

Conclusions

The hospital is falling short of the standards set out by the department; suggesting that changes need to be made to the process of CGA. There is currently no hospital-wide proforma for CGA; collecting data on the process is laborious and the triggers for CGA are not working as they should. Adding CGA to the hospital EPR would improve this. Highlighting the patients CFS will encourage referral for CGA. Specialities such as cardiology and respiratory can learn from the systems for the recognition and assessment of frailty in place on surgical wards.

Reference

1. Ellis, et al. Cochrane Review 2017.
49 Introducing A Geriatrician Into A Renal Service to Aid Decision-Making and Advance Care Planning
Authors: Aylett V , Mooney A , Kime Z , Windass A
Published: February 2020

Introduction

Over the past 30 years the population of end-stage renal disease (ESRD) patients has aged; the average age of starting dialysis is 67. Many have significant comorbidities, and the benefit for frail patients or those over 80 starting dialysis is uncertain.

Despite this, when older patients with ESRD are admitted to hospital as an emergency, few have an advance care plan or resuscitation decision. The Nephrologists in our hospital recognised that many of these patients might benefit from an out-patient Geriatrician review.

Methods

The Renal Low Clearance Clinic in Leeds assesses patients with ESRD who are approaching dialysis or conservative management. A Geriatrician was established within this setting, seeing patients in an alternate-week clinic. A collaborative approach with the pre-dialysis nurses led to identification of appropriate older patients. This work has been described elsewhere (KimeZ et al, abstract accepted for UK Kidney Week 2019.)

Use of comprehensive geriatric assessment (CGA) allowed for sensitive exploration of long-term goals, with discussions regarding plans in relation to renal replacement therapy and resuscitation, as well as generating continence, falls and memory clinic referrals. Where possible, family were involved.

Results

43 patients had completed encounters, with an average age of 79 (range 67-90.) The median Rockwood Frailty Score was 4 (range 1-7). 29 patients were seen at one visit, the rest requiring 2 or 3 appointments.

Prior to the encounter, only 2 patients had a DNACPR decision in place. Following this, 42 patients had had a resuscitation discussion and 18 patients chose DNACPR. Initially, only 7 patients had already chosen conservative management; this increased to 21 following discussions, including 7 who had previously opted for dialysis, the other 7 having been undecided. Those choosing conservative management were referred on to a specialist Renal-Palliative Care clinic.

Conclusions

Introducing a Geriatrician into the Low Clearance clinic has been welcomed by Renal colleagues and the effect has been apparent, with increasingly challenging patients being referred. CGA and advance care planning is feasible in this setting, which should have beneficial outcomes for patients in the longer term.
59 A Qualitative Study Evaluating Patient Education in the Pre-Operative Pathway for Elective Hip and Knee Arthroplasty at A Major London Teaching Hospital
Authors: Abbass R , Ahmed H , Asinger S , Haq I , Rahman A , Sharif F , Tonner E
Published: February 2020

Introduction

Rising demands for hip and knee arthroplasty have been met with incremental advancements in both implant design and surgical technique. Despite these advancements in the intraoperative setting, the preoperative pathway has remained largely unchanged. The resulting ineffective demand management and improper patient optimisation through education and engagement, has contributed to long waiting times and increasing surgical cancellations. This has in turn lead to both patient distress and the disruption of clinical workflow.

Aims

This study aimed to investigate the effectiveness of patient education in the pre-operative pathway for elective hip and knee arthroplasty, at Imperial College Healthcare NHS Trust, from the perspective of key clinical stakeholders.

Methods

16 Semi Structured Interviews were conducted with Healthcare professionals (HCPs) along the preoperative pathway. These included GPs, Orthopaedic Surgeons, Nurses, Anaesthetists, Orthogeriatricians, Occupational Therapists and Physiotherapists. Interviews were recorded, transcribed and thematically analysed. Sampling continued until information redundancy was reached.

Results

HCPs stressed that patient education lacked engagement & effectiveness. Whilst joint school (an MDT run seminar) is in place for patients before surgery, it was resource intensive meaning sessions were infrequent and often overcrowded.

Furthermore, not all patients were invited/attended joint school as a result of problems with scheduling and transport. Of those whom did, information retention was identified as a problem, highlighted by patients not bringing in medication, and failing to follow fasting instructions, leading to cancellations on the day of surgery. A significant proportion of elderly patients also needed additional and continued support in understanding and interpreting information, a key issue that was not addressed by traditional joint school.

Conclusions

This study has provided a more in-depth analysis of patient education in the pre-operative pathway revealing inadequate tailoring, and delivery of education material particularly for the older patient. Both timing, content and frequency of patient education could be improved in order to improve quality of care and reduce cancellations in turn improving the management of demand for orthopaedic services. Future studies may want to evaluate the use of digital technology in this area of the pathway in efforts to overcome these issues.
60 Post Inpatient Fall Medical Assessment (PIFMA) Performa Quality Improvement Project
Authors: Chan M , Tan C W , Mathew P
Published: February 2020

Introduction

Inpatient falls are the most commonly reported patient safety incidents and in the United Kingdom, there are 250,000 reported falls per year 1. A rapid response report (RRR) issued in 2011 by the NPSA highlighted need for improvement in identifying fractures and neurological observations. These figures reflect significant implications to patients’ health and financial burden to the NHS.

Aims

To improve assessment and documentation of inpatient falls assessment.

Methods

Two PDSA cycles were completed. First PDSA cycle established a baseline of post fall assessment and documentation in which raising awareness and teaching (RAT) to junior doctors was done. Second PDSA cycle identified room for further improvement and post inpatient fall medical assessment (PIFMA) Performa was developed to aid assessment and documentation for use of junior doctors. Feedback regarding the usefulness of the PIFMA Performa was collected via survey.

Results

The RAT intervention involved 30 patients of the Elderly wards in November and December 2017 and the PIFMA intervention involved 29 patients in all Medical wards in January and February 2019. The PIFMA Performa improved the time taken to review patients as per doctors survey. On comparing the RAT against PIFMA Performa interventions, documentation improved in the categories of physical examination (from 80% to 97%), neurological observations (from 49% to 98%), medication review (from 53% to 83%), and measuring lying standing blood pressure (from 83% to 90%).

Conclusions

Feedback from junior doctors states that the PIFMA Performa was certainly a very useful guidance tool and help to speed up documentation. These improvements only translated if junior doctors utilize the PIFMA Performa and so this is now being implemented in the trust policy. Further PDSA cycle can reassess if improvements truly represent the population cross-section.

References

1. The incidence and costs of inpatient falls in hospitals (2017), NHS improvement.

2. National Patient Safety Agency NPSA/2011/RRR001 (13 January 2011).
61 Targeting Elderly Patients on Inhaled Corticosteroids for Respiratory Optimisation
Authors: Wicks L , Kubler A , Robinson P
Published: February 2020

Introduction

Inhaled corticosteroids (ICS) are associated with increased rates of pneumonia, fracture and diabetes. ICS have limited short and long term benefits in COPD, and cessation of steroids in selected patients has been proven safe. We observed that a large proportion of inpatients in the geriatric service were prescribed ICS, and we aimed to review the reasoning for this and introduce a program of respiratory review in order to optimise care in these patients.

Methods

We conducted a retrospective audit of patients discharged from a geriatric service over a 3 month period. Sequential discharges were assessed for the presence and type of inhaled therapies, the documented diagnosis. After identifying high rates of inhaled therapy usage, we undertook a series of quality improvement interventions aimed at optimising respiratory care in these elderly patients. This included a guideline based protocol for reviewing respiratory diagnoses and prescriptions.

Results

In the retrospective analysis, 67/297 (22.5%) patients were discharged on inhaled therapy. 55/67 (82%) were discharged on an ICS, of which 20/67 (36%) were on high doses, equivalent to >1000micrograms of beclomethasone. Very few of these patients had evidence of inhaled therapy review during admission. 15/55 of these patients were given a discharge diagnosis of pneumonia; whilst only 6/55 were admitted with an exacerbation of their COPD. Our preliminary data suggest that a single paged protocol aimed at improving adherence to best practice lead to practice change: Dose modification has occurred in 50% of patients on ICS, leading to a reduction in steroid burden, and an annual reduction in prescription costs of £75 per patient reviewed. None of these patients have been re-admitted with respiratory exacerbations.

Conclusions

By introducing measures to assist in the review and modification of inhaled therapies, we were able to change practice. The alteration in practice led to reduction in prescription costs, and a reduced burden of inhaled corticosteroids. We propose that widespread encouragement of geriatrician led respiratory review could lead to harm reduction and cost saving in elderly inpatients.
64 Evaluating the Acute use of Rotigotine Patch for Dopaminergic Replacement in An Inpatient Population
Authors: Ibrahim H , Cavanagh A , Richfield E W
Published: February 2020

Introduction

Rotigotine, a trans-dermal dopamine agonist (DA), can be used acutely for inpatient populations and is an option in end of life (EoL) care for people with Parkinson’s disease (PD) where enteral (oral or naso-gastric) routes are no longer available or appropriate. Concerns regarding acute use of DAs in hospital include: i) difficulty achieving dopaminergic equivalence; ii) promotion of delirium; and iii) promotion of terminal agitation at EoL.

Methods

We retrospectively evaluated acute inpatient Rotigotine use in a UK teaching hospital. Prescriptions between January-June 2018 were identified from the pharmacy database and relevant inpatient records were analysed. The OPTIMAL calculator was used as a gold standard for dopaminergic conversion.

Results

33 eligible inpatients were identified. 13 (39%) patients were prescribed the recommended dose of Rotigotine; 7 (21%) higher and 13 (39%) lower than recommended dose. Of 22 (66%) patients with delirium, 18 (82%) inappropriately received the higher dose. 12 (36%) patients developed new or worsening delirium; and 6 (18%) developed new or worsening hallucinations. 19 (58%) patients were dead at time of evaluation with median survival of 22 days (range 1-207). For patients prescribed Rotigotine for EoL (n=13), median survival was 15 days (range 1-62); for patients not prescribed Rotigotine for EoL (n=20), median survival was 81 days (range 6-207). Of 13 (39%) patients prescribed Rotigotine for EoL, 9 (69%) had evidence of terminal agitation.

Conclusions

Acute conversion to Rotigotine remains problematic, despite availability of validated tools. Inappropriate dosing may precipitate or worsen delirium. Acute prescription of Rotigotine appears to act as a proxy marker for poor prognosis and could be a red flag for triggering advanced care planning. Little is published regarding use of Rotigotine at EoL, this data raises concerns regarding risk of terminal agitation and is an important area for further study.
71 Changes in Muscle Strength in Older Patients During Hospitalisation: A Prospective Repeated Measures Cohort Study
Authors: Hartley P , Romero-Ortuno R , Wellwood I , Deaton C
Published: February 2020

Introduction

Hospital associated deconditioning is a well-established phenomenon. Whilst mechanisms are not well understood, one is thought to be skeletal muscle wasting and/or loss of muscle strength. The primary aim of this study was to investigate changes in knee-extension muscle strength in older patients during and after an acute-hospital admission. We also aimed to explore the potential contributions of frailty, acute-illness severity and sedentary activity, with changes in knee-extension strength.

Methods

This was a prospective repeated-measures cohort study. Measurements of muscle strength and functional mobility were taken at recruitment, on day 7 of admission (or at discharge if earlier) and again 4-6 weeks post-hospitalisation. During the first 7 days of admission, daily measurements of muscle strength were taken.

Results

We recruited 70 participants, of which 65 had at least one repeated measure in hospital. Median age was 84 years, and participants participated in the study for a median of 6 days whilst in hospital, on average participants were ‘active’ for less than 4% of the day. Knee-extension strength significantly reduced by approximately 11% during hospitalisation, but no significant changes occurred post-hospitalisation. A repeated-measures mixed model included 292 observations from 62 participants and showed a significant decrease in the reduction in muscle strength as patients' sedentary time decreased on days 2 to 7 of the study. Additionally, the model showed that a higher frailty score, higher baseline knee-extension strength, lower baseline c-reactive protein levels were associated with greater loss in knee-extension strength during hospitalisation. Association between change in functional mobility after hospitalisation and change in knee-extension strength during hospitalisation was non-significant.

Conclusion

Our findings provide an important link in understanding the mechanisms and relative contributions of risk factors to hospital associated deconditioning. Further research is needed to confirm these findings and examine the impact of reducing sedentary time on muscle strength during and post-hospitalisation.
72 Prevalence of Reported and Unreported Vertebral Fractures in Ctpas in Older Adults Above 75 Years
Authors: Jones L , Singh S , Edwards C , Goyal N , Singh I
Published: February 2020

Introduction

Identifying vertebral fractures is prudent in the diagnosis of osteoporosis as they occur early in this hidden condition. Unfortunately, due to their unspecific presentation, only 25% are clinically recognised. Computerised Tomography Pulmonary Angiogram (CTPA) are frequently requested to confirm pulmonary thromboembolisms, but could also aid in detecting clinically silent vertebral fractures. Current literature suggests that less than one-third of incidental vertebral fractures are reported. The aim of this study is to measure the prevalence of vertebral fractures in CTPA and its relevance to clinical outcomes.

Methods

This is retrospective observational study based on the analysis of existing CTPA for acutely unwell patients admitted to medical assessment unit or A & E across three acute sites within Aneurin Bevan University Health board, Wales, UK between January and December 2015. All CTPA reports were reviewed for fragility factures and CTPA images were reassessed for any unreported vertebral fractures. Age and gender were recorded for all patients. Analysis was done for all patients in respect to subsequent fragility fractures and mortality. Difference of proportion test was used to compare two groups with and without vertebral fractures.

Results

179 CTPA were reviewed, 161 patients were included for further analysis. 14.3% (n=23/161) were reported to have a vertebral fracture, however only 8.7% (n=14/161) of reports used the correct terminology of ‘fracture’. On subsequent review, an additional 24.2% (n=39/161) vertebral fractures were noted. Therefore, overall prevalence of vertebral fractures was 38.5% (n=62/161). Only 9.1% (n=9/99) of patients without a vertebral fracture developed a subsequent fragility fracture. In comparison, 22.5% (n=14/62) of patients with a previous vertebral fracture sustained a new fragility fracture over next 4 years and this was significantly higher (p = 0.017). Overall mortality over 4 years follow-up was significantly higher for patients with vertebral fractures (64.5%, n=40/62) as compared to those without fractures (43.4%, n=43/99, p = 0.009). Only 48.4% (n=30/62) received osteoporosis treatment.

Conclusions

Vertebral fractures could be underreported by radiologists, likely due to human factors as they might be concentrating on the clinical scenario to exclude a pulmonary embolism. However, considering a significant higher mortality in patients with underlying vertebral fracture, it justifies that radiologists could be asked to examine sagittal view in the bone window for possible underlying vertebral fractures, to ensure osteoporosis is treated to guidance.
86 Fear of Falling as Measured by the Falls Efficacy Scale International Indicates Gait and Balance Abnormalities in Community Dwelling Older People
Authors: Gibbon J , Trundle H , Green D , Strassheim V , Linsley M , Parry S W
Published: February 2020

Background

Falls are common in community dwelling older people, and gait and balance abnormalities (GABAb) are a key modifiable risk factor, through strength and balance training. In addition, there is a strong relationship between fear of falling (FoF) and GABAb , though Falls Efficacy Scale-International version (FES-I) scores have never been examined in this context. Our aim was to determine whether FoF, as measured by the FES-I, is associated with GABAb, as determined by commonly used gait and balance tests.

Methods

Consecutive patients attending our community falls prevention service completed FES-I questionnaires, and had Gait Speed (GS), Five Times Sit to Stand (FTSTS) and Timed Up and Go (TUG) tests assessed as part of a multifactorial falls prevention assessment. Cut-offs for falls risk are provided in the table. Sensitivity and specificity values for a 16-item FES-I cut-off score of 23.5 (>23 signifying significant FoF) were evaluated using the area under a receiver operating characteristic curve (AUROC), along with positive and negative likelihood ratios (LR+/LR-).

Results

There were 991 participants, 352 male, 639 female, mean age 74.5 years, mean FES-I score 28.7 and 57.0% had experienced at least one fall in the previous year. Gait and balance test scores were moderately associated with FoF per FES-I ≥23.5 as shown in the table. Specificities and sensitivities for all three are similar to commonly used diagnostic tests such as exercise testing versus coronary angiography for coronary artery disease.

Conclusions

FoF as measured by the FES-I is associated with scores on commonly used gait and balance tests that indicate a high risk of falling. This study highlights the potential of using FES-I as a screening tool to identify community dwelling older adults at risk of falling who may benefit from strength and balance training rather than relying on physical tests that are rarely performed outside falls clinics and physiotherapy departments. This application may have utility both in opportunistic individual screening and community screening programmes.
88 The Truth Behind the Pubic Rami Fracture: Identification of Pelvic Fragility Fractures at A University Teaching Hospital
Authors: van Berkel D , Herschkovich O , Taylor R , Ong T , Sahota O
Published: February 2020

Introduction

Older patients presenting with pelvic fragility fractures (PFF) is an increasing epidemic. The most common pelvic fracture identified by plain radiograph is pubic rami fracture. These fractures are painful and often require admission to hospital. However, despite optimal analgesia, many of these patients struggle to mobilise and may have fractures of the posterior pelvic ring, which are overlooked and not visible on plain radiograph imaging. We aimed to quantify the number of patients progressing to further pelvic imaging in the form of computed tomography (CT) or magnetic resonance imaging (MRI) and the presence of concurrent fractures.

Methods

Prospective screening of pelvic imaging in patients aged over 70 years was undertaken at Nottingham University Hospitals NHS Trust over an 8-month period from October 2018.

Results

103 predominantly female (83%) patients were confirmed to have an acute fragility fracture of the pubic rami on plain radiograph. 19% of patients were discharged direct from the Emergency Department, 45% were admitted to Health Care of Older People (HCOP) teams, 30% to Trauma and Orthopaedic (T&O) teams and 6% to other specialities. 25% of the patients admitted underwent further pelvic imaging, which confirmed fragility fractures of the pubic rami in 88%, with 40% showing acetabular fractures and 68% showing sacral fractures of all types. A further 10 patients were diagnosed with pubic rami insufficiency fractures on further imaging, having had a normal initial radiograph, but had been admitted with poor mobility due to groin pain. In these 10 patients, 20% also had an acetabular fracture and 60% sacral fractures. Overall, 59% of patients with pubic rami fractures had an ipsilateral sacral fracture; a Type 1 Lateral Compression pelvic fracture by AO classification.

Conclusions

Pubic rami fractures are a significant problem in older people and often require admission to hospital. Further imaging confirms these fractures are complex, with co-existing fractures of the acetabulum and sacrum common. However despite this, only a quarter of patients admitted had further imaging. Where pelvic fractures are missed or severity not appreciated, appropriate pain control can be more difficult to achieve. With the potential for minimally invasive surgical options to aid pain management in sacral fractures, it may be prudent for all patients hospitalised with suspected or confirmed pelvic fracture to undergo further imaging.
89 Poor Attendance for DXA in Older People with A Low Trauma Fragility Fracture: A 6 Year Data Analysis of the Nottingham Fracture Liaison Service
Authors: Desai H , Hershkovich O , Ong T , Marshall L , Sahota O
Published: February 2020

Introduction

Hip Fractures are common and result in significant patient morbidity and increased mortality. Up to 40% of these patients have sustained a previous low-trauma fracture. The Department of Health advises that patients presenting with fragility fracture should have access to ‘Fracture Liaison Services (FLS)’. These are models of care which systematically identify patients at risk, assess bone health, treat patients (if needed) and follow patients up to support medication adherence.

Methods

Demographics of FLS patients between January 2012 and December 2017 was obtained retrospectively from the Nottingham University Hospitals FLS database. We examined DNA rates and further characteristics of these types of patients. Deprivation scores were deprived using the English indices of deprivation 2015 (1–Most deprived; 5-Least deprived). The 2016 cohort of patients were followed-up till January 2019 to assess for re-fractures.

Results

6528 high-risk patients were identified and referred to DXA. Mean (SD) age was 68±10.5 years [Females=5302 (81%)]. 1386 patients (21%) did not attend. High prevalence of non-attendance was in females [1032 patients (74%)] and the most deprived individuals [398 patients (29%)]. Females from the most deprived areas had the highest DNA rate [287 patients (29%)]. All eligible patients >75 years old were referred (n=1542 (100%), [Females=1284 (83%), non-attendance=473 (31%), non-attendance in females=390 (82%), highly deprived females=96 (25%)]. 826 patients were referred in 2016. Median follow-up time was 2.46 years (IQR 0.16–3.00 years). 52 patients (7%) re-fractured. 17 patients (33%) DNA their previous DXA scan [Females=12 patients (71%)].

Conclusions

Nottingham FLS have identified patients with fragility fractures that are high-risk for further fractures. Despite a dedicated FLS there is a DNA of 21%. Many patients that DNA are generally considered as having a high-risk of further fractures; females, older age and more deprived. Further studies are needed to explore why patients do not attend for bone density scanning.
93 Telemedicine Implementation in Croydon Care Homes
Authors: Smith J , Tunbridge R , Houser K , Serdoz D
Published: February 2020

Background

Croydon has one of the largest numbers of care homes of any London borough. Following the success of telemedicine in the Airedale and Partners NHS vanguard, care home telemedicine has been commissioned in Croydon.

Despite encouraging results for some individual services, the formal evidence base for telemedicine remains ambiguous. We aim to further our understanding of the use, perceptions and implementation of the telemedicine service in the care homes of Croydon.

Methods

Results are being collected from care homes including:Usage (e.g. time of day, patient/caller intention)Outcomes (e.g. GP calls, conveyances to hospital)

In addition, a survey of GPs and care homes was completed, with redistribution of the survey planned six months after introduction of telemedicine.

Results

In the first four months data of the service, 42 care homes have implemented telemedicine since Jan 2019. For these care homes, the results show a reduction in ambulance call outs of 7% and a reduction in conveyances to hospital of 4%. In the care homes that have been using the service on a regular basis, the reduction in call outs and conveyances is considerably bigger. There is also increasing use of the telemedicine service in preference to calling a GP. This data will become more robust and analysed further with the ongoing use of the service.

Initial survey results highlight the varied opinions of telemedicine, including perceived change in workload and quality of care, and will be repeated in August 2019 to assess any change in perceptions.

Discussion

The emerging data shows encouraging results for those care homes that are high users of telemedicine service. However, there is significant time and resource involved to ensure uptake and correct use of telemedicine in care homes. With the survey, we have uncovered a varied understanding and perception of telemedicine across the Croydon system prior to its implementation in care homes and will discover if these perceptions change following its increasing use.

We will present the successes and challenges to the implementation of the telemedicine service in care homes so far, then discuss the opportunities for care home telemedicine in Croydon for the future.
99 Approaches to Eating and Drinking with Acknowledged Risk: A Systematic Review
Authors: Soar N , Birns J , Sommerville P , Lang A , Archer S
Published: February 2020

Introduction

Patients with dysphagia may consider eating and drinking with acknowledged risk (EDAR) instead of artificial hydration/nutrition. Timely consideration of complex issues is required including dysphagia reversibility, prognosis, risk/benefit discussions, patient wishes, their capacity, best interests and advanced care planning. This study aimed to ascertain if EDAR protocols improve care through a systematic literature review.

Methods

PUBMED, MEDLINE, CINAHL and EMBASE were searched for English language articles to May ‘19 with terms related to EDAR, dysphagia and end of life. Articles and conference abstracts with original data were agreed for inclusion by two independent reviewers. Levels of evidence were assessed using the Sackett scale (Cook et al, Chest. 1995; 4: 227–230). Study themes were identified and discussed.

Results

12 articles met the inclusion criteria with varied methodology. The highest level of evidence was III (cohort study) and most were limited to patients with dementia, stroke, in older person’s wards or residential homes. 4 articles described a systematic approach to EDAR for in-patients and reported reductions in days nil-by-mouth until feeding plans are made and improvements in documentation of decision making, nutrition plans and capacity assessment. Other major themes included the need for an EDAR protocol, staff, patient and carer/family knowledge of EDAR, development of a protocol and the language of “risk feeding”. Formal meta-analysis was not possible due to the level and mix of methodology.

Conclusions

There is a paucity of evidence to determine if EDAR protocols improve care. However support is emerging for a coordinated approach to managing EDAR. Findings suggest having a protocol is not enough; education, training and communication within teams and with patients and carers is essential and this justifies further work. The lack of research into the impact of EDAR protocols on patient and carer experience means they must be central to any future work.
101 A Posture and Mobility Training Package for Care Home Staff: Results of A Cluster Randomised Controlled Feasibility Trial
Authors: Graham L , Cundill B , Ellwood A , Fisher J , Goodwin M , Hawkins R , Holland M , Hull K , Hulme C , Kelly C , Williams R , Farrin A , Forster A
Published: February 2020

Introduction

Provision of care for care home residents with complex needs is challenging. Physiotherapy and activity interventions can improve physical well-being but are often time-limited and resource intensive. A sustainable approach is to enhance the confidence, skills and abilities of care home staff. This trial assessed the feasibility of undertaking a definitive evaluation of the Skilful Care Training Package (SCTP) - a posture and mobility training programme developed by physiotherapists for care home staff.

Methods

A parallel-group, cluster randomised controlled feasibility trial was undertaken in ten care homes in Yorkshire. Five were randomised to receive SCTP, five to usual care. SCTP was delivered by specialist physiotherapists, with the intention of training all direct care staff. Following consent, data were collected from and about residents with restricted mobility (those fulfilling the eligibility criteria) at baseline, three and six months post-randomisation by blinded researchers. Outcome measurement included resident mobility, posture, pain and quality of life. The feasibility of recruitment, retention, data collection and intervention delivery was assessed.

Results

All residents (348) at participating homes were screened for eligibility. 250 were eligible and 146 took part. Follow-up was balanced between arms, with an overall loss-to-follow-up rate of 28.8% at six months. Where residents were available for six-month follow-up, proxy data provision was excellent (97.1% - 100% of expected data). Difficulty collecting data directly from residents was experienced (43.3% of expected data) due to high levels of cognitive impairment. Staff attendance at training met or was close to pre-specified criteria for acceptability in three homes, with 63.0%, 63.6% and 65.8% direct care staff attending all sessions, and >85% attending at least one session across all three homes. However attendance fell short of acceptability in two homes, with only 21.4% and 12.5% staff attending all sessions.

Conclusions

It is feasible to recruit and follow-up residents in a randomised trial comparing SCTP and usual care. Proxy data collection is a successful method, but collection of data from residents is difficult. Intervention delivery success was variable, illustrating heterogeneity between care homes. Future research will be informed by learning from those homes with greater intervention compliance. Work should be undertaken to investigate how best to collect meaningful data from residents.
103 A Review of Reviews of Emergency Department Interventions for Older People: Outcomes, Costs and Implementation Factors
Authors: van Oppen J , Preston L , Ablard S , Buckley Woods H , Mason S , Conroy S
Published: February 2020

Introduction

Older people’s emergency care is an international public health priority and remains sub-optimal in the UK. Strategies are needed to manage older patients sensitively and effectively. We reviewed emergency care interventions, evaluating evidence for outcomes, costs, and implementation.

Methods

We developed and registered (with PROSPERO, CRD42018111461) a review of reviews protocol. Screening was according to inclusion criteria for subject and reporting standards. Data were extracted and summarised in tabular and narrative form. Quality was assessed using AMSTAR2 and Joanna Briggs Institute tools. Due to intervention and outcome heterogeneity, findings were synthesised narratively. McCusker’s Elder-Friendly Emergency Department assessment tool was used as a classification framework.

Results

Eighteen review articles and three conference abstracts fulfilled inclusion criteria. The majority were systematic reviews, with four using meta-analysis. Fourteen reviews reported interventions initiated or wholly delivered within the ED, and four focussed on quality indicators or patient preferences.

Confidence was limited to each review’s interpretation of primary studies. Descriptions of interventions were inconsistent, and there was high variability in reporting standards. Interventions mostly focussed on screening and assessment, discharge planning, referrals and follow-up, and multi-disciplinary team composition and professional activities. 26 patient and health service outcomes were reported, including admissions and readmissions, length of stay, mortality, functional decline, and quality of life.

Conclusions

Our review of reviews demonstrated that the current, extensive evidence base of review studies lacks complexity, with limited or no evidence for the effectiveness of interventions; reviews commonly called for more primary research using rigorous methods. There is little review evidence for factors influencing implementation.

There was evidence that among interventions initiated in ED, those continued into the community yielded better outcomes. Service metrics (as valued by care commissioners) were evaluated as intervention outcomes more frequently than person-centred attributes (as valued by older people). Interventions were broadly holistic in nature.