bluuebunny/crossref_metadata_2025 huggingface dataset:
95 Do Not Attempt Resuscitation: all or nothing?
Authors: Carvalho J , Gibbons C , Ramjohn J , Ahmed B , Heberger M , Quigley L , Finan K
Published: September 2023

Background

Do Not Attempt Resuscitation (DNAR) orders may be implemented when patients do not wish to receive Cardio-Pulmonary Resuscitation (CPR) or when CPR is deemed non-beneficial. Complex ethical and medical considerations influence these decisions, emphasising the need for accurate documentation as per national policies. Our aim was to assess comprehensive documentation of DNAR decisions and healthcare providers’ opinions on managing patients with DNAR orders.

Methods

We conducted a point-prevalence chart review of adult inpatients with a DNAR order on March 2nd, 2023.We surveyed healthcare providers using a structured tool and analysed the data using Excel.

Results

We identified 22 (n = 22) charts for review. All charts had a DNAR form, but only 31.8% (7) had documented discussion details. 54.5% (12) lacked a discussion with the patient regarding the DNAR decision, and 58.3% (7) lacked documentation explaining the reasoning. 72.7% (16) lacked clear documentation on the reasoning for the DNAR status decision. Regarding healthcare providers’ opinions on patients with DNAR status, we received 46 completed questionnaires (n = 46). Most respondents believed simple bedside investigations and non-invasive interventions were appropriate for DNAR patients. However, there was a discrepancy in opinion regarding more invasive interventions, such as Naso-Gastric Tube placement (52%) or inotropic support (48%). 84.8% (39) of staff believe there is a distinction between palliative patients and those designated as DNAR. 80.4% (37) of nursing staff reported hesitancy in discussing DNAR status with doctors when patients deteriorate. 58.7% (27) of staff believed their approach to care changes when a patient is labelled DNAR.

Conclusion

Our audit demonstrates the need for improved DNAR status documentation. Current practices do not meet national guidelines, creating ambiguity and subsequent confusion during emergencies. This may be exacerbated by disparities in hospital staff opinion regarding DNAR patients, highlighting the importance of establishing local policies to improve staff education and patient care.
140 Introduction of a post fall medical review pro forma for hospital inpatients
Authors: Daly S , Ramjohn J , O'Sullivan F
Published: September 2023

Background

Falls are the most common adverse incident in Irish hospital inpatients. 30–50% of inpatient falls result in injury. Older people are more likely to fall and are more likely to sustain an injury. The post fall medical review is critical to assess why a patient fell and if they sustained any injuries. We aimed to audit the quality of the post fall medical review compared to the ‘HSE Service User Falls’ guideline in a university hospital and if the introduction of a post fall pro forma improved the quality of this review.

Methods

We retrospectively audited the post fall medical review entries of 20 charts of patients who had fallen in hospital. We assessed details such as patient/doctor identifiers, history, examination, management and falls prevention. We introduced a post fall medical review pro forma on two wards in the hospital to aid doctors in their medical review. We then re-audited the quality of the medical review of 9 patients who fell over a two months period and were reviewed using the pro forma. We compared these results to our first audit.

Results

The post fall medical review pro forma improved the quality of the medical review in multiple domains. 30% of doctors asked if there had been a head strike pre pro forma versus 100% who asked with the pro forma. Joint examination improved from 45% pre to 100% post pro forma. Hip strike history taking improved from 15% to 89%. 70% of doctors recorded the date and 15% recorded the time of assessment pre pro forma. 100% recorded both with the pro forma.

Conclusion

The post fall pro forma resulted in quality improvement of the post fall medical review. It is a memory aid and also encourages accurate documentation. This pro forma will be introduced hospital wide to improve patient care.
147 PRIME-COG study: grip strength, anthropometrics and cognitive decline
Authors: McAlinden M , Linden G , McKay G , McEvoy C , Farsi D , Teeling J , Passmore P , Holmes C , Patterson C , McGuinness B
Published: September 2023

Background

Measurement of hand grip strength is a validated measure of physical strength. While anthropometric measurements including waist, hip and mid-upper-arm circumference, are validated for physical health. Evidence has suggested grip strength and anthropometrics to be associated with cognitive impairment and dementia. The relationship between these variables and risk of mild cognitive impairment (MCI) or dementia was investigated in a cohort of 70–90-year-old men residing in Northern Ireland.

Methods

The PRIME-COG study is nested within the Prospective Epidemiological Study of Myocardial Infarction (PRIME) study. Data collection for PRIME-COG included collection of lifestyle and demographic information. A comprehensive cognitive assessment, anthropometric measurements, and hand grip strength were measured by dementia research nurses from the Northern Ireland Clinical Research Network. Logistic regression models were performed to assess the association between hand grip strength and anthropometric measures and the composite cognitive endpoint MCI/dementia.

Results

Analysis identified that low hand grip strength was associated with MCI/dementia, although this did not reach statistical significance (OR 1.39, p = 0.18). Larger hip circumference was associated with reduced risk of MCI/dementia in the study population (fully adjusted model, OR 0.93, P = 0.01), while BMI was non-significantly associated with an increased risk (OR 1.22, p = 0.58).

Conclusion

Within the PRIME-COG cohort, low grip strength was associated with a 39% increased risk of MCI/dementia. Whilst not statistically significant, this supports the importance of grip strength as a clinical tool in the assessment of physical health in older adults. Larger hip circumference was significantly associated with a 7% reduced risk of MCI/dementia, while higher BMI was associated with a 22% increased risk, although this was not significant. Results from this study add to the evidence demonstrating the association between cognitive function and physical well-being.
157 Budget impact analysis of Holter monitors provision in an outpatient clinic
Authors: Marion I , Power D
Published: September 2023

Background

Outpatient clinic attendees (aged >64) commonly present with falls, dizziness, syncope and palpitations. The most common non-invasive investigation ordered includes continuous ambulatory electrocardiography monitoring, namely the Holter monitor. The clinic is outsourcing Holter monitor requests to the Cardiology Department, with a long waiting list. If the patient wishes the test to be done sooner in a private hospital, it costs between 160 to 295 euros, covered by the patient’s private healthcare insurance.

Methods

A budget analysis was carried out to further evaluate by provisioning 5 Holter monitors in the outpatient clinic to quicken patient turnover and reduce the cardiology department waiting list. The intervention scope was limited to the designated clinic of approximately 450 patients a month. The intervention is not for generating revenue for the clinic. The budget analysis doesn’t include sensitivity analysis from the best-case towards worst-case scenarios of Holter frequency usage and duration of Holter monitoring. The objectives of the proposed change are to lessen the turnaround time by 20% for the patients from being assessed until discharge from the clinic without having delayed investigation of the Holter monitor, to have a timely and accurate diagnosis of suspected arrhythmia and the appropriate management within the new intervention.

Results

The decision tree, utilising the Decision analytic modelling, resource identification, cost implication, estimated changes including 2-hour staff training, capital, year one to year five costs, potential cost savings year-on-year, cost-per-wear comparison against the private hospital provider, pre and post-intervention scenario analysis were constructed.

Conclusion

The budget impact analysis designed a simple cost calculator to add additional tests of Holter monitors that rely on the decision model approach. It shows a potential cost saving within a five-year horizon and increases the number of patients’ attendance by optimising patient turnover. Apart from the cost and organisation, there are other positive impacts towards financial and clinical areas, ensuring high-quality service for the population.
158 Delirium as a predictor of admission in the emergency department
Authors: Dillon A , Edge L , Flynn S , Kirwan A , Romero-Ortuno R
Published: September 2023

Background

Frailty intervention teams are now commonplace in Emergency Departments (EDs). A geriatric assessment in the ED should be multidimensional and include demographics, details of the presenting complaint, frailty, and delirium. The aim of the present review was to establish which of these dimensions was most predictive of patient disposition (i.e. admit vs. discharge) in the ED of a large university hospital.

Methods

Data was reviewed from ED attendees aged ≥65 years assessed by the frailty intervention team over a three-month period. Age, sex, and whether the presenting complaint was a fall were recorded. Frailty was measured with the Clinical Frailty Scale (CFS), and delirium with the 4AT. Receiver Operating Characteristic (ROC) curves and Areas Under the Curve (AUC) were compared for the ability of age, CFS and 4AT to predict patient disposition. A multivariate binary logistic regression model was computed to assess how CFS and 4AT independently predicted patient disposition, whilst controlling for age, sex and fall as presenting complaint.

Results

Data from 217 patients was analysed (mean age 81.7, range 67–99 years; 66.4% women; 29.5% presenting with falls; median CFS 5; mean 4AT 1). The AUCs for age, CFS ad 4AT to predict admission were 0.59 (95% CI: 0.51–0.67, p = 0.033), 0.65 (0.58–0.73, p < 0.001), and 0.70 (0.62–0.78, p < 0.001), respectively. In the regression model, the only significant independent predictor of admission was the 4AT (OR 1.70, 95% CI: 1.37–2.12, p < 0.001).

Conclusion

In the ED interface, delirium was a stronger prediction of admission than demographics, fall as the presenting complaint, and frailty. While delirium is a marker of illness acuity, frailty refers to the pre-illness baseline. The measurement of delirium in the ED is important as a predictor of patient disposition, while early delirium assessment may help to improve the time-to-disposition interval.
168 A quality improvement initiative to enhance dementia inclusivity within the physical environment of an older persons’ acute hospital ward
Authors: Sayers J , Ryan C
Published: September 2023

Background

There are currently over 64,000 people living with dementia in Ireland, this number is expected to double by 2045. Direct observation from multiple disciplines highlighted a large cohort of people living with dementia experiencing disorientation, wandering, and falls at ward level. National Guidelines and Strategies state that physical ward environments should be a key consideration for dementia care. Research shows that physical ward environments can be adapted to reduce confusion and agitation and improve wayfinding for those living with dementia.

Methods

An environmental ward audit was conducted through direct observation, using the environmental checklist from the Irish National Audit of Dementia (INAD-2). The results of the audit were compared with national standards which showed reduced compliance. Adaptations and/or modifications including the installation of orientation clocks, orientation whiteboards and increasing signage and labels to the physical ward were implemented to increase compliance. The ward was re-audited to assess change.

Results

The results highlighted increased compliance with national standards. Direct observations from the multidisciplinary team identified increased wayfinding and orientation for patients living with dementia on the ward. Multidisciplinary education on dementia inclusivity is essential in fostering a person centred approach to dementia care in the acute ward environment.

Conclusion

Multidisciplinary collaboration and commitment to dementia inclusive care may enhance the experience of those living with dementia in the acute hospital setting. Barriers such as infection control measures emphasised the need for a collaborative approach to overcome challenges and facilitate change.
177 Embracing choice: perspectives of older workers on extended working lives
Authors: Greene J , Collins M L
Published: September 2023

Background

Proposals to extend working lives are a frequent policy response to increasing older populations and associated pressures on state pension systems. However, all the consequences of a later retirement age are as yet unknown, with the perspectives of people potentially the first cohort of workers encouraged to remain in the workforce under-explored.

Methods

We conducted exploratory semi-structured interviews with 22 people aged between 51 and 63 in service industry occupations in Ireland. Falling just above low-income thresholds, this group were asked about their preparations for retirement, their views on continuing to work beyond anticipated retirement age and what measures, if any, can be implemented to facilitate working later in life. A thematic analysis was performed to provide a rich and detailed account of the perspectives of older workers as they approached retirement age.

Results

We found a general acceptance of working later in life, however this was contingent on several factors. The overarching enabler was continuing in good health with financial status a key underpinning motivator. For participants with insecure housing, patchwork employment histories and inadequate pension provisions, there was an impetus to continue working to generate savings before retirement. Often with less secure employment trajectories than previous generations, a leisurely retirement lifestyle was a diminishing prospect for our study participants. Working in multi-generational workplaces with the opportunity to shift to mentor roles was welcomed. As retirement approaches, measures such as reducing working hours while protecting existing welfare benefits would encourage people to remain in work for longer.

Conclusion

The complex and individual nature of continuing to work beyond expected retirement age requires flexible policy responses. An individualised approach to retirement which recognises the increasingly diverse nature of employment over the life-course is needed. This research contributes to advancing knowledge on how the choices of older workers can be facilitated in the context of our rapidly growing older population.
184 Paying attention to the feasibility of daily delirium screening in an acute hospital setting
Authors: O'Donnell N , Doyle M , Laffan S , Sheehan M , Gardener P , Hearne S , Doyle P , O'Regan N
Published: September 2023

Background

Delirium is highly prevalent, yet two-thirds of cases remain undetected. Irish national guidance recommends daily delirium screening for all acute hospital in-patients at risk of delirium, including older patients. We conducted a series of stakeholder workshops to identify the screening tool considered most feasible for daily delirium screening by staff nurses in our hospital.

Methods

We identified four tools validated for daily delirium screening from the Scottish Intercollegiate Guidelines Network guidelines on ‘Risk Reduction and Management of Delirium’. These included the DOS-13 (Delirium Observation Screening Scale); RADAR (Recognising Acute Delirium As part of your Routine); mRASS (modified Richmond Agitation Screening Scale); and SQiD (Single Question in Delirium). Two workshops for local nursing delirium champions were held to discuss the feasibility of each of these instruments. Workshops commenced with teaching on delirium prevention, management and the rationale for daily screening. Factors relating to the time taken to conduct the assessment, training required, suitability for nursing staff use, diagnostic accuracy, and other issues relating to feasibility were explored.

Results

The RADAR was considered the instrument with the best balance between feasibility of implementation and diagnostic accuracy. The mRASS was preferred as the next best option, however there was concern that this instrument would require significantly more training. The DOS-13 was considered too time-consuming and too detailed, however it was proposed as a useful behavioural charting tool in patients with known delirium. Although the SQiD was considered the quickest test to conduct, it was felt that staff changeover would lead to reduced diagnostic accuracy.

Conclusion

RADAR was deemed the test of choice for daily delirium assessment in UHW acute wards. A delirium care bundle incorporating the RADAR was hence developed and training of staff has commenced. The next steps will be to evaluate its feasibility and efficacy in the real-world setting.
186 Experiences of implementing a group intervention targeting sarcopenia in an integrated care for older persons hub
Authors: Grant E , Phelan N , Bambrick P
Published: September 2023

Background

Sarcopenia is associated with declining mobility, falls, frailty, and increased mortality. Research suggests resistance exercises and ensuring adequate protein intake can improve muscle mass, strength and function.

Methods

Screening for probable sarcopenia was introduced as part of the comprehensive geriatric assessment in the hub. Suitable candidates who screened as having probable sarcopenia were offered a group intervention facilitated by a physiotherapist and a dietitian, followed by an 8 week at home self-management programme. Alongside objective assessments of outcomes, the clinicians conducting the program also undertook a process of reflection on the experience, to provide a qualitative analysis that might inform future work.

Results

The main barrier identified to the group intervention was enrolment. The primary reason for this appeared to be the presence of other comorbidities that precluded participation. These included active medical conditions, complex social issues, advanced cognitive impairment, complex falls, or malnutrition requiring more specialist intervention. The main facilitator identified was an engaged multidisciplinary team (MDT), willing to upskill to screen for sarcopenia and proactive about discussing the intervention with potential participants. Another facilitator was the practice of contacting participants at the midpoint, to check on compliance and provide encouragement.

Conclusion

Several conclusions were achieved through a qualitative reflection on the experience. Engaging and upskilling team members and therapist support were seen as facilitators, whilst recruitment was the most significant barrier. During reflection it was suggested that excluding those that did not screen for probable sarcopenia (53% of all screened) may have been a missed opportunity for promotion and prevention. These learnings will be used to inform the design of future such interventions. Despite the challenges encountered, there was a consensus among the MDT that offering a group intervention is a practical way to begin to address sarcopenia within the limited resources of a community hub.
212 Sarcopenia case finding: impact of body mass index on calf circumference measure
Authors: Salawu A , Glynn M , Kelly K , Dragos C , Cabansay C , Lowther K
Published: September 2023

Background

Calf Circumference (CC) is recommended by the European Working Group on Sarcopenia in Older People (EWGSOP) as part of the sarcopenia assessment algorithm. Clinicians’ are concern about accuracy of use in patients with high Body Mass Index (BMI) 25- 40 kg/m2 and low BMI < 18.5 kg/m2. The aims of this study are to: (1) Compare prevalence of sarcopenia using Raw and BMI adjusted CC measures and (2) Examine CC association with gait speed and Clinical Frailty Score (CFS).

Methods

An observational study of over 65 years in rehabilitation setting. All data collected as part of routine physiotherapy care. Premorbid CFS recorded and Gait speed (m/s) over 6meters calculated. The fattest part of the calf was measured to give Raw CC corrected to the nearest centimetres (cm). Raw CC measures of patients with BMI < 18.5, 25–29, 30–39 and ≥ 40 kg/m2 were adjusted for by adding 4 cm, subtracting 3, 7,12 cm respectively (Gonzalez et al, 2021) to give Adjusted CC. Cut off values for sarcopenia by gender as recommended by EWGSOP. Data was analysed using Pearson’ correlation and t- test. Significant values set at p ≤ 0.05 and r = 1.

Results

n = 99, 54% female. Low BMI and high BMI was 13% and 37% respectively with mean CFS of 5.4. Walking speed was slow, mean = 0.21 m/s. Moderate positive correlation observed between Raw and Adjusted CC measures (r = 0.713, p = 0.0001). Sarcopenia prevalence was 30% using Raw CC compared to 54% with Adjusted CC (p < 0.004). Weak association recorded for CC measures with gait- speed and with CFS; (r = 0.124 and 0.123). No significant difference in Raw and Adjusted CC measures in Frail (5,6,7) and Non- frail (1,2,3,4) groups; [33.9(4.8) vs 32.3(4.16)]; p = 0.26 and [34.1(5.7) vs 32.4(4.6)]; p = 0.07.

Conclusion

Sarcopenia prevalence was higher with Adjusted CC. Clinicians’ awareness of impact of BMI on calf circumference is important in sarcopenia screening.
221 A one-year audit of intracranial haemorrhages that presented to a level 4 hospital and died within 30 days
Authors: Casey R , Whittle C , Jones B , O’Regan N , Cooke J , Mulcahy R , Pope G
Published: September 2023

Background

Spontaneous Intra-Cerebral Haemorrhage (ICH) constitutes 15% of all strokes and has a 1 month mortality of 40%. Different prognostic models are used but the most widely used model is the ICH score. Predictors for 30-day mortality include greater ICH volume, infratentorial location of ICH, low Glasgow Coma Scale (GCS), older age, and intraventricular extension. We audited all non-traumatic ICH that presented to a level 4 Hospital and died within 30 days in 2021.

Methods

We retrospectively collected all adult patients with imaging-confirmed (CT- or MRI-scan) non-traumatic ICH and died within 30 days. Patients were identified via FAST Call register. Exclusion criteria were traumatic ICH or non-parenchymal haemorrhage, haemorrhagic transformation of ischemic stroke, brain tumour associated haemorrhage. Data included age, GCS on admission, co-morbidities, Modified Rankin Score (MRS) pre admission, oral anticoagulation/anti-platelet use/time, patient’s blood pressure recordings. If the patient was referred to Neurosurgery, advice was collated. Haemorrhagic properties were measured on CT: supra- or infratentorial, intraventricular extension, and ICH volume (ABC/2 method). ICH Scores were calculated.

Results

29 ICH were identified with a 30 day mortality of 37.9%(11/29) and a mean age of 80.9 years. Median-MRS pre-admission was 3, GCS on arrival was 9(3–13). 5/11(45%) were admitted to the Stroke Unit. 5 patients were on anticoagulation and 3 received a reversal agent. 8 patients had a systolic BP 150-220 mmHg on arrival of whom 3/8(38%) achieved a target BP of ≤140 mmHg at 2 hours of diagnosis. Mean volume of ICH was 45.6mls. Median ICH score was 3.

Conclusion

29 patients presented with an ICH with a 30 day mortality of 37.9%. These were frail and multi-morbid patients. 45% were admitted to the stroke unit and 38% achieved optimal blood pressure control within 2 hours. This highlight two areas that could be improved to ensure optimum patient care.
233 Residents’ experiences of COVID-19 pandemic in a Long-Term Care Facility in Ireland: a qualitative study
Authors: Savolainen K , Ahern A
Published: September 2023

Background

COVID-19 fundamentally impacted Long-Term Care Facilities (LTCFs) in Ireland and worldwide. The pandemic resulted in a series of restrictions and limited older people in LTCFs in their daily lives. Learning and understanding the impact COVID-19 had on older people in LTCFs is crucial for future care delivery planning, as those in LTCFs are some of the frailest in society. This study aimed to provide a perspective of that understanding.

Methods

The study’s objective was to capture a description of the residents’ in-depth experience of COVID-19 in a communal long-term care facility for older people. Individual semi-structured interviews with residents who could consent were held between September to November 2021.

Results

Ten residents participated in the interview study. Their average stay in the LTC facility at the time of the interview was 3.25 years, with the shortest stay being 1.5 years and the longest being seven years. The gender distribution was 50/50 among the ten residents interviewed. Four main themes were concluded from the transcriptions; coping, loss & grief, resilience and social activities. The themes are interlinked and provide insight into residents’ ability to adapt to critical changes in the LTC facility in an extremely challenging period.

Conclusion

Although residents mentioned loss, not only about people but also the loss in doing activities, being active within the LTC facilities was essential and helped with coping with COVID-19 restrictions. Understanding residents’ experiences of COVID-19 in nursing homes is crucial to implement improvements as well as acknowledging the impact of COVID-19. Older people in LTCFs are already marginalised by their need for care. Further understanding of older people in LTC experience of a pandemic such as COVID-19 is required. This requires innovative solutions to capture the experience of all living in LTC facilities.
252 An audit of the inpatient course of patients with Parkinson’s Disease in a level four hospital in 2019
Authors: Reidy C , Farrell T , Pope G , Mello S , Bambrick P , O'Regan N , Cooke J , Mulcahy R
Published: September 2023

Background

Studies show that patients with Parkinson’s Disease (PD) are more often admitted to acute hospitals and have increased Length-of-Stay (LoS) compared to age-matched controls associated with higher morbidity and mortality. This review was undertaken as the outcomes of patients with PD have not been evaluated in this level 4 hospital. Previous work locally has shown a lack of knowledge regarding the inpatient management of PD.

Methods

Data was collected from a retrospective chart review (115 admissions coded with PD in 2019). 10 patients were selected from medical, surgical, and orthopaedic admissions respectively (36 admissions). Charts were reviewed recording demographics, LoS, Emergency Department (ED) management, complications, outcomes, and readmission rates. Data was collected, stored, and analysed using Microsoft Excel.

Results

Median age of patients was 80 years. 44% were female. Median length of stay was 15.5 days. PD was documented in 97% of patients in ED, of whom 11% of patients received their PD medications in ED. 78% of patients had a history of falls, but only 20% had lying and standing blood pressure recorded. 38% had delirium as an inpatient. 42% of patients were made nil by mouth (NPO) during their stay, 87% of these secondary to peri-procedural fasting. Medications were held in 71% of procedures. Only 69% of discharge summaries were readily available. 6 patients (20%) were readmitted within 3 months.

Conclusion

This review highlights several areas for improvement in the management of inpatients with PD in a level four hospital. Initial interventions include education sessions for healthcare staff and review of ED pathways. PD medication management will also be reviewed. Accessible electric discharge summaries are also a key area for improvement. We aim to assess patients with PD experience of their inpatient journey as the next step in our quality improvement project. We will reaudit in 6 months.
268 Specialist stroke rehabilitation needs in a tertiary hospital—are needs being met?
Authors: Gannon E , Healy L , O’Donovan C , Blackburne H , Arrigen G , Barry P , James K
Published: September 2023

Background

Stroke specific rehabilitation is essential to recovery and return to independence following acute stroke. With increasing cases and improvements in stroke care rehabilitation needs are rising, placing significant pressures on acute stroke units and acute hospital services. We used a point prevalence study to assess the rehabilitation needs of our stroke service.

Methods

Patients admitted under the stroke service were identified using the electronic patient admissions system on February 17th, 2023. Data was collected by teams of two healthcare professionals. Data collected: demographics, ward location; most appropriate location of care—Hospital, Community, Rehabilitation Unit; Clinical Frailty Score (CFS); Rehabilitation Complexity Score (RCS); estimated Length of Stay (LoS).

Results

53 patients admitted under the stroke service, 60% (32/53) patients were on the stroke unit, 40% (21/53) on an outlier ward, 9% (5/53) in the emergency department. Female 45% (24/53) Male 55% (29/53). Of patients >75 years 67% (22/32) had a CFS > 4. 41% (22/53) had primary rehabilitation needs, 30% (16/53) community, and 28% (15/53) hospital care. 17% (9/53) had an estimated LoS > 3 months of those 55% (5/9) had primary rehabilitation needs that could be in a rehabilitation unit. Average RCS 9.7, average RCS 12.6 for patients with an estimated LoS > 3 months.

Conclusion

Our study shows that limited access to suitable rehabilitation facilities has a direct impact on the coordination of stroke services in the acute setting. A high proportion of patients were not located on the stroke unit, an intervention shown to reduce mortality and disability. This study highlights the importance of ongoing improvement of rehabilitation services.
280 Prevalence of prescribing high anticholinergic scoring medications among over 65-year-old patients in primary care
Authors: O'Hagan L
Published: September 2023

Background

The effects of anticholinergic drugs are widespread because acetylcholine is involved in regulating various bodily functions, both in the Central Nervous System (CNS) and the Peripheral Nervous System (PNS). By blocking the action of acetylcholine at CNS muscarinic receptors, anticholinergic drugs can lead to cognitive effects such as impaired attention, decreased learning ability, and memory difficulties. Blocking the PNS muscarinic receptors with anticholinergic drugs can lead to side effects such as urinary retention, constipation, and alterations in heart rate. Considering these issues, it is generally advisable to use anticholinergic drugs with caution in the elderly population as an anticholinergic score of 3 or more is associated with increased risk of confusion, falls and death. This audit seeks to determine the prevalence of the higher scoring Anticholinergic drugs (3) among the older population in a city centre GP Practice.

Methods

The website www.acbcalc.com provides a comprehensive list of medications with an Anticholinergic burden score of 3. Using this list of 48 commonly prescribed medicines, each one was searched on the practice clnical system individually and the number of patients currently prescribed each medicine documented.

Results

Approximately 5.45% of patients over 65 yrs (N = 2,770) are currently prescribed a medicine with an Anticholinergic score of 3. The most commonly prescribed are Amitriptyline (1.52%), Solifenacin (1.01%), Quetiapine (0.79%), Olanzapine (0.61%).

Conclusion

While anticholinergic medications can prove useful clinical interventions in certain patients, it is generally accepted that a burden score of 3 or more increases the patient’s risk of confusion, falls and death. Patients who have a high Anticholinergic score should have their medicines optimised through a shared decision making framework regularly, to ensure current therapy is beneficial and alternatives considered. An automated audit tool could be created within the primary care clinical system to score each patient’s anticholinergic burden and thus help target polypharmacy reviews.
285 ‘To communicate or not, that is not the question!’
Authors: Higgins S , Duggan A , Loughlin E , Waters R , Walsh T
Published: September 2023

Background

Safe patient care necessitates accurate and timely patient communication between acute, community, and primary care services. Given the complexities of care of older adults, including polypharmacy and deprescribing, reliable communication between all services is essential. This has been identified as a requirement prior to discharge. This audit aimed to assess compliance with discharge communication across the Geriatrics Service.

Methods

This audit was carried out from 10th–17th April 2023. Consecutive patient discharges across Stroke and Acute Geriatrics Services were assessed for data including age, gender, date of admission, date of discharge, discharge summary completion, and date and time of validation of the discharge summary. The Electronic Discharge Summary (EDS) and Inpatient Patient Management Systems (IPMS) systems were used for data collection. Data was analysed descriptively. Standards used were The Integrated Care Guidance: A Practical Guide To Discharge And Transfer From Hospital (HSE), and the National Standard For Patient Discharge Summary Information (HIQA).

Results

107 patient records were assessed, median age 72.2 years (IQR 29.1), 48.6% female (n = 52). 91.5% (n = 98) patients had discharge summaries completed, 86.7% (n = 85) of which were validated. When including all validated discharge summaries, the median time to validation was 0.4 hours (IQR 79.43) post discharge. Median time to validation pre-discharge was 1.5 hours (IQR 3.1) and represented 54.2% (n = 58) of patients. Median time to validation post discharge was 21.8 hours (IQR 149.76) and represented 31.7% (n = 27) of patients.

Conclusion

This audit highlights a high level of compliance with discharge summary completion. Areas for improvement include higher levels of completion prior to discharge, and ensuring that all summaries are validated to allow for printing and distribution. This will help ensure seamless and safe communication between all levels of care of older adults.
310 Identifying and characterising the ‘Bermuda Triangle’ in older adults referred for Comprehensive Geriatric Assessment: its association with falls and polypharmacy
Authors: Madders G , Sayers K , King L , Donnellan C
Published: September 2023

Background

The Bermuda Triangle comprising orthostatic hypotension (OH), cognitive impairment (CI) and mobility impairment (MI) is independently associated with a 4 fold risk of future falls. The objective of this study was to evaluate the prevalence of this triad in older persons attending for Comprehensive Geriatric Assessment (CGA) by a Community Specialist Team. The baseline characteristics of patients with and without the triad were compared. We examined the association of this triad with incident falls and polypharmacy.

Methods

A cross-sectional retrospective descriptive study was undertaken on all patients >65 years referred for CGA between September 2022 and March 2023 (n = 166). The standard criteria for OH detection was used. A positive AD8 in ≥2 domains signified a CI. Gait abnormality or use of a gait aid defined MI. Polypharmacy was defined as ≥5 prescribed medications. The data was analysed using descriptive statistics.

Results

The prevalence of the ‘Bermuda Triangle’ was 12% (n = 21). Within this cohort, 66.6% had fallen in the past year. The mean number of falls was 4. These patients were twice as likely to be more functionally dependent (Modified Barthel Index ≤15) and clinically frail (CFS ≥ 5). The prevalence of polypharmacy was 86% (n = 18) compared with 80% in patients without the triad. A high Anticholinergic Burden Score was identified in 57% (n = 12). Specialist pharmacy intervention was required in 67% (n = 14) of this cohort.

Conclusion

The Bermuda Triangle increases falls risk. Factors contributing to these syndromes may be modifiable. Identification of this cohort may help with prioritisation of multifaceted interventions for this high risk group.
311 Nutrition and dietetics on a Frailty at the Front Door Team, what does it look like?
Authors: Cronin L
Published: September 2023

Background

A dietitian was introduced to the Frailty at the Front Door team (FFDT) in January 2022. The introduction of the Malnutrition Screening Tool (MST) to the Comprehensive Geriatric Assessment (CGA) resulted in a 47% increase in dietetic referrals. The aim of this study was to understand the characteristics of this population and how intervention was initiated.

Methods

Over a five month period, data was collected from the CGAs administered. Gender, Clinical Frailty Score (CFS), MST score (high risk of malnutrition is defined as MST ≥2), method of referral, patients admitted under a specialty, referrals to Community Nutrition and Dietetics Services (CNDS) and those discharged from dietetics. The data was prospectively entered into an excel spreadsheet and analysed using descriptive statistics.

Results

206 frail older adults (≥ 75 yrs) were referred and seen for dietetic intervention. Male to female ratio was 1: 1.75.The mean CFS was 5.8. 89% (n = 183) had MST ≥2. 83% (n = 171) of referrals were made by FFDT, 6% (n = 12) were referred via the hospitals’ electronic referral system. 64% (n = 132) were admitted to the acute hospital while a further 20% (n = 41) were referred to CNDS. The remaining 16% were either transferred to a different hospital or discharged from the dietetics service. Of those admitted, the data was broken down into the top 5 specialities; Geriatrics: 18% (n = 37), Acute Medicine: 16.5% (n = 34), Endocrinology: 12% (n = 25), General Medicine: 10% (n = 20) and Respiratory: 8.2% (n = 17).

Conclusion

High risk of malnutrition is highly prevalent in frail older adults presenting to the ED and through a number of medical specialties. Increased awareness identifies these patients so that targeted interventions early can reduce adverse outcomes in hospital or the community. Screening for malnutrition with a dietitian embedded in the FFDT identifies a much bigger proportion of those who need intervention than the traditional referral method.
317 Analysing the social history aspects of an integrated care comprehensive geriatric assessment incorporating patients views and wishes
Authors: Lynch A , Dennehy K , Reddin C , Costello M , Canavan M , Murphy R
Published: September 2023

Background

An evaluation of social well-being is an important component of a Comprehensive Geriatric Assessment (CGA). There is no clear guidance about how best to structure and examine these factors as part of a CGA. We sought to examine current practice with respect to the collection of information from a social care perspective across different integrated care CGA proformas.

Methods

We completed a cross sectional study of the social care domain of integrated care based CGA proformas. All operational leads for each integrated care hub in the country were contacted and invited to share their local CGA. We completed a thematic analysis of the social care section including social, financial and wellbeing assessments.

Results

We included 16 different CGAs that are in use across different integrated care hubs. All CGAs had a dedicated section for assessing social history with variability in what was included in different CGAs. Patient’s wishes and expectations were commonly included but the manner in which they were collected and emphasis varied. 7 (43%) specifically captured whether the patient has an enduring power of attorney in place, 5 (31%) collected information about formal advanced care directives, and 2 (12%) enquired about nominated assisted decision makers. Ability to manage finances was captured through the Lawton Brody IADL scale in two CGAs. Half of CGAs included a section to capture carer strain and the term ‘next of kin’ was used in 6 of 16 CGAs.

Conclusion

There is significant heterogeneity in the structure of the social care section of a CGAs across different integrated care hubs, particularly with respect to capturing information surrounding advanced care planning. Signposting of patients’ wishes and expectations was useful for focusing on patient-centred care.
324 Statin prescribing in ischaemic stroke patients: quality improvement of an acute stroke ward in a model 4 tertiary teaching hospital
Authors: Ahern E , Dennehy K , Gannon E , Rubel M H , Ryan P , Healy L
Published: September 2023

Background

Stroke remains the leading cause of long-term disability. High cholesterol is associated with increased risk of stroke. Treatment with high intensity statins, as recommended by the SPARCL trial, is effective in reducing recurrence risk. The Medicines Management Programme recommends atorvastatin as the preferred drug, which can be given at any time of the day. With the majority of medications administered in the morning, clustering of medications is associated with higher adherence rates. Low statin adherence is associated with greater risk of death.

Methods

A point prevalence audit was carried out in an dedicated stroke ward in a tertiary model 4 teaching hospital. The data collected included sex, age, number of days since admission, pre-admission statin administration, current statin prescribed, dose, time of administration and change in current vs pre-admission prescription. Results were collected, analysed and compared with the above evidence.

Results

21 inpatients with ischaemic stroke were included. Age ranged from 36 to 89 years, with a mean age of 73. 52% were female. Number of days since admission ranged from 1 to 165, with an average of 48. 13 patients were taking a statin prior to presentation, and 19 at time of data collection. Prescribed statins included atorvastatin and rosuvastatin. 76% had a change in statin type or dose during admission. 95% of patients were prescribed their statin at night time.

Conclusion

Appropriate statin prescribing is an essential part of secondary prevention. Long acting statin should be prescribed at a time that optimises compliance. We hypothesise that long acting statins including atorvastatin/rosuvastatin when given in the morning with other medications will increase compliancy. In line with the PDSA cycle, a planned education session, in conjunction with the pharmacy department, will take place focusing on atorvastatin/rosuvastatin prescribing, with re-audit following this, to ensure sustained change in practice.
325 Demographics of patients presenting to the Rapid Access Frailty Assessment Unit (RAFAU) in a regional hospital in 2023
Authors: Sibthorpe L , Conroy K , Goulden E , Donnelly T , McGlynn J
Published: September 2023

Background

The RAFAU is a five-day rapid-access, multidisciplinary service including Medical, Physiotherapy and Occupational therapy. The aim is to improve biopsychosocial outcomes and ultimately avoid hospital admission. It opened in May 2021 and an expansion of service provision has occurred since then based on ongoing service evaluations.

Methods

Data was manually recorded each day from an existing proforma on Excel, allowing for analysis to be done for the dates including 03/01/2023 to 22/05/2023.

Results

202 attendances were recorded. Similar numbers were seen in the age groups 70–75 (20.3%), 76–80 (22.8%), 81–85 (19.3%) and 86–90 (21.8%) with smaller numbers in those <70 (9.9) and over the age of 91 (5%). 1 person’s age was undocumented. Approximately 40% of attendees were male and 60% were female. 38.6% of patients had a CFS of ≤3. 55.9% had a CFS of 4–6. 4% had a CFS of ≥7. The reasons for referral included medical review (38.6%), mobility and falls (36.1%) and cognition and memory (23.3%). GP’s referrals totalled 66.8% with other sources of referrals including the Emergency Department (ED) and Rapid Access Frailty Team based in the ED (21.8%), Hospital Consultants (7.4%) and allied health practitioners (4%).

Conclusion

The RAFAU provides an important and timely service to the catchment area of the regional hospital, particularly in assistance to primary care and community services. Only a small number were below the age of 70 or above the age of 90. Approximately 60% were of moderate to severe frailty. As the number of attendances increase, the service provision in RAFAU as well as community services may require further expansion.
333 Integrated care and impact on length of Time-At-Home, a retrospective cohort study
Authors: Loughlin E , Murphy R , Canavan M
Published: September 2023

Background

The Integrated Care Programme for Older People (ICPOP) shifts care from unscheduled hospital attendance to planned ambulatory community care. The impact of these services should be measured to inform service delivery in the provision of sustainable healthcare for older adults. We aimed to measure the average Time-At-Home for patients attending an ICPOP service. Time-At-Home was defined as the time from review to next unscheduled attendance.

Methods

A retrospective cohort study was carried out on consecutive attendances at the ICPOP service, between January–March 2023 inclusive. Electronic health records of the Comprehensive Geriatric Assessment were reviewed and any subsequent unscheduled hospital attendance at our institution were recorded to measure the length of Time-At-Home for each patient (days). Predictors of longer Time-At-Home were calculated by regression analysis.

Results

191 patients were analysed, 56% female (n = 107), mean age 81.9 years (SD 6.5), 82.7% GP referrals (n = 158). Reasons for referral included memory assessment (n = 90), falls (n = 43), frailty (n = 28), decreased mobility (n = 12), Parkinson’s disease (n = 6), home supports (n = 4) and miscellaneous (n = 8). Mean Clinical Frailty Score (CFS) was 4.72 (SD 1.6), median number of medications was 9 (IQR 5). Median duration of follow-up was 109 days (IQR 61 days). 25.7% (n = 49) of patients were admitted during period of follow-up. Reasons for attendance included delirium/memory-related issues (n = 4), falls/pre-syncope/syncope (n = 13), infection (n = 12), mobility (n = 4) and miscellaneous (n = 17). Those admitted were more likely have been referred from an acute hospital service (p = 0.03), had higher Clinical Frailty Scores (CFS) (p = 0.02) and higher degrees of polypharmacy (p = 0.01). Median length of Time-At-Home was 61 days (IQR 91). There was no difference in length of Time-At-Home by age, CFS or number of medications.

Conclusion

Reasons for and predictors of acute hospital attendance following ICPOP review are important to measure. This will inform the delivery of services going forward and areas to address to further reduce acute hospital attendance rates.