bluuebunny/crossref_metadata_2025 huggingface dataset:
55 The Case for A Best-Interest Meeting Decision Toolkit to Guide Preferred Place of Care and Interventions For Community Dwelling Older People Who Lack Mental Capacity
Authors: Dar A , Wiltshire R , Wright P N
Published: March 2021

Introduction

The Hammersmith and Fulham Community Independence Service (CIS), runs a “virtual ward” to allow people to remain independent in their own homes where possible.

Place-of-care decisions made for community-dwelling older people who lack capacity are formulated in a best-interest meeting (BIM), involving health and social care professionals, family and carers.

Often BIMs centre around beliefs and wishes of the patient or family but fail to objectively evaluate risks and mitigants of staying at home versus placement.

We observed that BIMs were not being held on a consistent basis, and when held lacked the necessary structure for an effective decision-making forum.

Even experienced professionals find it difficult to chair BIMs because of the complexity of the decision-making process. Not all involved parties may be represented.

We found BIMs more likely to be held, attended and effective when structured to identify the major relevant considerations.

Method

The CIS “virtual ward” team developed a BIM decision toolkit, comprising: a check-list of risks and mitigants for home versus care home; a list of required attendees; who should document and chair the meeting; and who should action the interventions raised.

From 6th January to 25th October 2019, BIMs were held for 48 patients on the CIS “virtual ward”.

Results

234 interventions were carried out following toolkit-led BIMs.

1 month after BIM, 34 of 44 patients’ wishes (77%) were honoured (3 not recorded, 1 died).

3 months after BIM, 23 of 31 patients’ wishes (74%) were honoured (15 not recorded, 2 died).

Case studies are included in the presentation.

Conclusion

We developed a toolkit to support decision-making for older community dwellers who lack capacity regarding their place of care. The toolkit assures standardisation and structure to minimise bias, whilst recognising personal beliefs and preferences. It enables any member of the multidisciplinary team to hold and lead a BIM, to reliably identify appropriate interventions and care plans which may not otherwise have been implemented or recognised.

The majority of the patients reviewed using the BIM toolkit remained in their preferred place of care well after the team’s interventions.

Further evaluation is required to compare CIS BIM toolkit-based outcomes against other community services which do not use this toolkit, and appraise the toolkit in a hospital setting.
60 Front Door Specialist Frailty MDT Working at MFT NHS Trust—The Therapy Team Poster Presentation
Authors: Turner H , Bennett G , Hurst S
Published: March 2021

Introduction

The therapy team consists of physiotherapists, Occupational therapists and therapy technicians working generically to deliver a comprehensive therapy assessment to patients presenting in our Emergency Department, Clinical Decisions Unit and Medical Admissions Unit between the hours of 08:00–18:00 7 days a week. The therapists provide the hospitals frailty service in ED and MAU with early therapy assessment and intervention, supporting the provision of a Comprehensive Geriatric Assessment. The aims of our service are to provide early therapy assessment of our most vulnerable patients to avoid unnecessary hospital admissions and reduce readmission rates, and for those requiring hospital care to provide early mobilisation and discharge planning to reduce length of stay and complications associated with hospital admission. We provide the therapy component of the CGA as part of the specialist frailty MDT service and act as an interface with local community health and social services.

Method

A full review of our frailty MDT service was undertaken and a re-allocation of our resources and staff was piloted in July 2019.

During this pilot our therapy staff presence was re-distributed allowing greater patient numbers to be assessed promptly on their arrival to ED.

This adjustment supported the Frailty MDT actions of:

Results

Data collection showed total referrals to therapy increased from 67 (June 2019) to 160 (July 2019). In July same day discharges were at 43%; discharges ≥72 hours 24%; 7 day readmission at 9%; 28 day readmissions at 11% and 38% were referred to community services.

Conclusion

These changes enabled us to provide a full MDT frailty service to frail older people presenting at our ED in a timely manner and to a larger number of suitable patients.
61 Outcomes of An Advanced Nurse Practitioner-Led Pops Service in A District General Hospital
Authors: Irimia A M , Tennant A , Waldron A , Bashir N
Published: March 2021

Introduction

There is an increased need for geriatrician input to older adults outside of the medical wards. There is a lack of geriatricians to contribute to these services. An example includes the Proactive care of older people undergoing surgery (POPS) service where geriatricians perform comprehensive geriatric assessment (CGA) to identify comorbidities and geriatric syndromes which may lead to poor post-operative outcomes. Advanced nurse practitioners (ANP) are highly skilled staff members and are increasingly used to provide the POPS service. We wanted to review the outcomes of our Nurse Led POPS service.

Methods

Patients aged over 70 admitted as an emergency to upper gastrointestinal and colorectal surgery were assessed by the POPS ANP using CGA. Assessments were completed on a proforma. Data was collected prospectively on a data collection form documenting new issues detected and interventions made. The results were analysed using an Excel spreadsheet.

Results

147 patients were reviewed by the ANP between November 2018 and March 2019. All patients were screened for frailty, cognitive impairment and delirium. 37.41% were clinically frail, 17.72% had cognitive impairment and 11.56% had delirium. New issues were identified in 90.47% of these patients; polypharmacy (80.27%), new catheter (53.74%), weight loss (46.94%), incontinence (36.05%), falls (29.25%) and pain (25.17%). Medical issues were also identified including electrolyte abnormalities (47% patients), acute kidney injury (22% patients), cardiac issues (8% patients) and respiratory problems (7% patients). Additional interventions included stopping medication (27.89%), starting new medication (20.41%), requesting further investigations (97.28%), referring to allied health professionals (95.24%) and advanced care planning (15.65%).

Conclusions

A POPS ANP can effectively conduct CGA identifying new medical issues and geriatric syndromes missed by the surgical teams in an acute setting.
62 A Retrospective Observational Study Into the Correct Administration of Rivaroxaban: Is it Being Taken with Food?
Authors: Spurring E , Donnelly G
Published: March 2021

Intro

In July 2019 the MHRA issued a drug safety update reminding healthcare professionals that rivaroxaban should be taken with food. This came after they received a number of thromboembolic events reported in patients prescribed rivaroxaban, thought to be linked with incorrect ingestion on an empty stomach [1].

Our aim was to establish if the healthcare professionals in our department had this knowledge and to audit our current dispensing practice to assess if our hospitalised patient cohort were being exposed to any increased risk.

Methods

A retrospective study was conducted using electronic data from 21 patients that were prescribed rivaroxaban across 14 medical wards. A questionnaire was used to establish the staff’s knowledge.

Results

Of the surveyed healthcare professionals, 79% knew that rivaroxaban should be taken with food (86% of nurses and 79% of doctors). Despite this only 17% of patients took the tablet with food. 75% of patients had rivaroxaban incorrectly dispensed over an hour post meal and 8% were uncertain due to poor documentation. Only 14% of healthcare professionals were aware that in those with swallowing difficulties, rivaroxaban can be crushed.

Conclusions

In our department most of the healthcare professionals had a good academic knowledge of correct rivaroxaban administration, however we have demonstrated that this is failing to correctly influence clinical practice. 75% of patients taking Rivaroxaban in hospital are being subjected to increased risk due to the hospital environment. This was found to relate to the difference in timing of the drug dispensing round in comparison to meal times. As part of the roll out of electronic prescribing in our trust, a warning now shows when both prescribing and dispensing Rivaroxaban to attempt to improve this highlighted risk. We have also highlighted this to the ward managers and at our governance meeting.

Reference

1. Drug Safety Update volume 12, issue 12: July 2019: 3.
63 Nocturia—An Underappreciated “Symptom” of Obstructive Sleep Apnoea?
Authors: Yeong K , Santiapillai J , Arumainayagam B N , Murray P , Tadtayev S
Published: March 2021

Nocturia (>2 per night) is the most frequent cause of disturbed sleep in older people. Poor sleep results in reduced health related QoL, and is linked to the development of cognitive impairment. Nocturia can result in an increase risk of falls and fractures, and is also an independent risk factor for mortality.

The prevalence of norturia is high in the elderly, and it has been reported to be around 77.1% in elderly women and 93% in men. Historically, this bothersome symptom is thought to be mainly a result of bladder outflow obstruction due to prostatic hypertrophy or overactive bladder. More recently, nocturia has been associated witsh nocturnal polyuria (NPu) and obstructive sleep apnoea (OSA). The relationship between OSA and NPu is not fully understood but it is thought that the negative intrathoracic pressure generated by OSA causes an increase in Atrial Natriuretic Peptide (ANP) secretion, resulting in NPu.

Nocturia is highly prevalent in patients with severe OSA. However, patients are usually unaware that they have sleep apnoea, and are therefore more likely to present to urology or geriatric services. It is important that OSA is not overlooked in these clinics as intervention with CPAP is highly effective in reducing symptoms.

Here, we present the result of using the STOP-Bang questionnaire in 71 consecutive patients presenting to our urology service with nocturia. The average age was 73 years (range 34-88), male-to-female ratio 14:1 and median nocturia frequency of 4. 42 patients were at risk of undiagnosed sleep apnoea (median STOP-Bang Score of 5)—35 were referred for sleep studies, 4 patients declined and 3 patients were not referred. Overall, 31 out of 35 sleep studies (88.6%) demonstrated the presence of OSA; of these 23 (74.2%) confirmed moderate or severe OSA. All patients with OSA were seen and treated by the respiratory service. Overall, median nocturia frequency decreased from 4 to 1 across the whole cohort, from a combination of CPAP therapy, bladder outlet procedures and desmopressin.

Conclusion

At least a third of patients (32%) with bothersome nocturia have an undiagnosed clinically-significant OSA. Identification of OSA improves outcomes across the whole cohort, because nocturia in patients without OSA is more likely to respond to bladder outlet procedures and desmopressin.
64 Improving the Monitoring and Awareness of Fluid Balance on A Hip Fracture Ward
Authors: Pickles H , Addy V
Published: March 2021

Introduction

Fluid balance charts are frequently incomplete and inaccurate. At present our Trust does not offer fluid balance training to all ward staff. In addition, drinks given to patients by visitors are not usually documented on the fluid balance charts. The goals of this quality improvement project were therefore to:

Methods

Using the PDSA model a questionnaire was given to ward staff as a scoping exercise to identify the deficiencies in fluid balance education prior to the intervention and fluid balance charts were analyzed. The intervention involved:

Results

Pre-intervention questionnaires demonstrated that 31% of staff asked were not clear on the meaning of fluid balance and 88% felt that more fluid balance awareness was needed on the ward. In addition, 7/8 randomly selected fluid balance charts were incorrectly completed. Post intervention 87% understood the meaning of “fluid balance” monitoring and 7/8 fluid balance charts were correctly completed.

Conclusion

The intervention educated all ward staff and improved the accuracy of fluid balance monitoring. It also provided information and guidance to non-medical staff and visitors regarding fluid balance monitoring. Following the success of the project the intervention is being rolled out across the Trust alongside education sessions for staff.
66 Is “Medically Fit for Discharge” Ambiguous and Misleading to Patients? A Health Service Study
Authors: Alegbeleye J , Kaneshamoorthy M
Published: March 2021

Introduction

NHS England (2015) Monthly Delayed Transfer of Care Situation Report states that “Medically Fit for discharge” or “Clinically optimized” is used at the point at which care and assessment can safely be continued in a non-acute setting. However, elderly patients are either frail or unlikely to be fit physically or medically before they are discharged from hospitals. A number of complaint meetings with patients and relatives suggested that doctors and healthcare professionals should consider changing the language used during discharges. The aim of the study was to identify the challenges with the use of variable languages and to provide standardization of the discharge Languages that seems appropriate for the patients within our organization.

Method

In February 2019, a discussion with major stakeholders at Basildon and Thurrock University Hospital F. NHS Trust including Medical Director and management teams, suggested the need to conduct a staff survey to explore the need for standardization of discharge languages. The survey was sent by emails to healthcare professionals between 6th June 2019 and 1st July 2019. There were 115 responders.

Results

The proportion of responders between doctors and other allied healthcare professionals was 58% and 42% respectively. 75% of responders reported the use of the term “Medically fit” or “Clinically optimized for discharge” had been challenged by patients or relatives. 61% of staff disapproved the term “Medically Fit for Discharge” and 64% suggested this needed to be changed to “Medically Stable For Discharge” which is more acceptable and meaningful language. Our survey showed that the reasons for the change are that a wrong language is not only ambiguous but misleading amongst our respondents.

Conclusion

This study has shown concern amongst the staff regarding the language used during the discharge process. Not only is “Medically Fit for Discharge” controversial but occasionally causes dispute between patient/relatives and healthcare professionals. Our project has helped standardize the cultural language to “Medically Stable For Discharge”. This resonates better to patients and enhances their experience and also reduces anxiety caused by ambiguous language. Further study will be required to know how this reduces the complaints rate and delayed transfer of care within our Health service.
69 Continuous and Regular Live Feedback is Required to Maintain An Improvement in the Quality of Discharge Summaries. Shop 75 +
Authors: Cross H , Evans J , Pederson A , Yidana D , Carey D , Robey R , Vilches-Moraga A , Gaillemin O
Published: March 2021

Background

This quality improvement project aims to improve communication between secondary and primary care at the time of hospital discharge of older patients.

Introduction

Discharge summaries (DS) are a key component of communication between secondary and primary care. Poor quality DS are associated with poorer outcomes in terms of adverse events [1], readmissions [2] and medication errors [3]. There is NICE and AMRC guidance on what constitutes a good DS [4, 5].

Method

Prospective review of DS from a range of wards was completed in August 2017 against a detailed data tool. A random selection of DS from the same wards was audited monthly from November 2017 onwards. A novel live-feedback system was introduced to the same wards in February 2018 so that the teams completing DS received feedback on how well their summaries complied with the recommendations and what areas needed improvement. A change in staffing lead to a break in the delivery of monthly feedback to the ward teams from April to September 2019 when it was re-commenced.

Results

In the majority of areas there has been an increase in the quality of the DS from the beginning of the project until March 2019 when the regular feedback interventions were suspended. There was a decrease in the quality of summaries in July and August 2019, followed by an increase as regular feedback interventions recommenced in September 2019. The aggregate results of the four main components of DS (follow-up actions, medicines, clinical summary, and functional assessment), scored “good” in 13% of DS at baseline, 40% in March 2019, 20% in July 2019 and 31% in October 2019.

Conclusions

The suspension of regular direct interventions resulted in a significant deterioration in the quality of discharge summaries, and this improved quickly after reintroduction of PDSA cycles in key areas. Continuous quality improvement requires uninterrupted focus on regular live feedback.

References

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

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

3. Romero-Ortuno et al. Age Ageing 2012; 41: 684–9.
70 Improving the Documentation of DNACPR Decisions Following the Transition to Electronic Record Keeping
Authors: Jackson L , Saund J , Donnelly G
Published: March 2021

Background

This quality improvement project was based at The Royal Bolton Hospital across our four Complex Care wards.

Introduction

We have recently transferred to electronic record keeping. At these points of transition there may be an adverse impact on the quality of patient care and safety. We recognised on our own ward there were inaccuracies between the required paper form and electronic documentation of DNACPR decisions. Consequently, we wanted to review and improve the accuracy of our DNACPR documentation to ensure safe and effective patient care.

Methods

To gauge the scope of the problem we audited 87 patient’s electronic and paper notes, with no exclusion criteria. We reviewed whether each patient had a formal resuscitation decision, and if a DNACPR decision had been made whether we met our hospital policy by having:

93% of the 87 patient’s had an active decision regarding resuscitation, with a DNACPR decision documented for 50 patients. Of these 50 patients only 11 had all three forms of documentation. More worryingly, there were discrepancies in the documented DNACPR decisions for 11 patients across paper and electronic records.

Interventions

We escalated our concerns to the Clinical Governance team who sent out a trust wide SBAR highlighting this as an urgent clinical issue. On a directorate level we incorporated DNACPR decision documentation into our afternoon safety huddle and arranged informal teaching for medical, nursing and administrative staff.

Results

Reassuringly, the subsequent re-audit of 90 patient’s notes showed only one patient to have a discrepancy between paper and electronic documentation. We saw an improvement to 98% having paper forms in the right bedside notes and 100% having a documented electronic DNACPR decision.

Conclusion

Through local education and trust-wide dissemination of our expected standards we have seen some improvement. We recognise the importance of maintaining this, and importantly that there is still work to be done. The electronic “Resuscitation and treatment escalation plan” is still rarely completed and provides important information on escalation of care and thus will be the focus of a further educational intervention.
72 Surviving the Epidemic That Confronts Us—Fracture Liaison Service Evaluation Data
Authors: Larcombe T , Lisk R A , Yeong K F
Published: March 2021

Introduction

1 in 2 women and 1 in 5 men over the age of 50 will break a bone and a significant proportion will suffer from osteoporosis.A fragility fracture will double the risk of future fractures. Between 1990 and 2000, there was nearly a 25% increase in hip fractures worldwide. A hip fracture is one of the most devastating, and often terminal, injury for an older person.

Intervention

The Fracture Liaison Service (FLS) captures patients aged 50 and above that present to fracture clinic with possible fragility fractures with the aim to reduce further fracture incidence. Patients are assessed for osteoporosis and recommendations made for treatment.

Results

Here we present the results of our FLS service evaluation after 6 years in operation, using the rate of hip fractures (number of hip fractures/Emergency Department [ED] attendances over 75’s) as a surrogate marker for effectiveness.

Evaluation Summary

Trend analysis of our data indicates a reduction in the number of patients attending the Trust with fractured neck of femur (NOF) despite the increase in ED attendances. This is against the trend nationally where fractured NOF numbers are rising (National Hip Fracture Database, accessed online August 2019).

Next steps

The FLS to attempt to comprehensively capture muscular-skeletal patients and to consider opportunities present to target case finding to high risk cohorts.
77 National Audit of Care At the End of Life (NACEL)—Round Two Findings
Authors: Hibbert D
Published: March 2021

NACEL is a national comparative audit of the quality and outcomes of care experienced by the dying person and those important to them during the final admission in acute and community hospitals in England and Wales. Mental health inpatient providers participated in the first round but excluded from the second round.

NACEL round two, undertaken during 2019/20, comprised:

Data was collected between June and October 2019. 175 trusts in England and 8 Welsh organisations took part in at least one element of NACEL (97% of eligible organisations).

Key findings include

Recognising the possibility of imminent death: The possibility that the patient may die was documented in 88% of cases. The median time from recognition of dying to death was 41 hours (36 hours in the first round).

Individual plan of care: 71% of patients, where it had been recognised that the patient was dying (Category 1 deaths), had an individualised end of life care plan. Of the patients who did not have an individualised plan of care, in 45% of these cases, the time from recognition of dying to death was more than 24 hours.

Families’ and others’ experience of care: 80% of Quality Survey respondents rated the quality of care delivered to the patient as outstanding/excellent/good and 75% rated the care provided to families/others as outstanding/excellent/good. However, one-fifth of responses reported that the families’/others’ needs were not asked about.

Individual plan of care: 80% of Quality Survey respondents believed that hospital was the “right” place to die; however, 20% reported there was a lack of peace and privacy.

Workforce

Most hospitals (99%) have access to a specialist palliative care service. 36% of hospitals have a face-to-face specialist palliative care service (doctor and/or nurse) available 8 hours a day, 7 days a week.

NACEL round three will start in 2021.
82 Person-Centred Emergency Care Outcome Measurement For Older People Living with Frailty
Authors: van Oppen J
Published: March 2021

Introduction

Health outcome goals are the results individuals seek from healthcare. These may incorporate holistic themes including function, mood, and quality of life. People living with frailty have poorer outcomes from even short hospital stays. They benefit from person-centred, goal-directed care over protocol-driven pathway approaches. This could be improved by monitoring attainment of health outcome goals.

Methods

A systematic review for older people’s health outcome goals in emergency care was conducted using narrative synthesis. A qualitative study based on grounded theory expanded the outcome framework to include people living with frailty. People with cognitive and communication barriers were included in semi-structured interviews. Discussions focussed on the events and outcomes sought from emergency care.

Results

Older people’s health outcome goals for emergency care were classified as efficient and comprehensive care, sensitivity towards vulnerability, and person-centred informed care. The importance of understanding individual perceptions was explicit. Research generally recruited based on age rather than physiological and functional state, and did not assess for impact of frailty on healthcare perceptions. The interview study was paused due to the COVID-19 pandemic. Initial results showed a predominance of person-centred and holistic care themes among health outcome goals. Participants’ most common goal for emergency care was relief of symptoms: people often had pain. Participants mostly had severe frailty and wanted their mobility to be assessed, with goals of recovering their functional baseline. While participants had confidence in healthcare professionals and were generally willing to “do as we are told to feel better”, they expected to undergo at least basic tests in order to receive a working diagnosis for their problem. People wanted to understand their illness and for explanations to be communicated to their relatives. Next steps Patient-reported outcome measures (PROMs) for this range of emergency care outcomes are being identified for field-testing in acute settings.
87 Improving the Delivery of Written Communication to Patients Presenting to the Frailty Assessment Service Following A Fall
Authors: Suthermaraj G
Published: March 2021

Introduction

NICE guidelines recommend for healthcare professionals to give patients both verbal and written information when explaining how to prevent further falls at home, how to cope with falls and where they can seek further advice or assistance. Most of the patients seen by the Frailty Assessment Service (FAS) at Northumbria Specialist Emergency Care Hospital (NSECH) will remain at a high falls risk even on discharge. An emphasis should be made on educating patients about how best they can manage their risks at home to prevent further falls.

Method

Over a six month period, data on patients seen by the FAS team was collected by reviewing electronic case notes and the daily patient list to identify presenting complaint and whether a falls leaflet was given on discharge.

Results

Following three cycles of intervention, the rate of falls leaflet distribution to patients discharged following a fall increased from an initial 0% to 24%, then to 55% and finally to 72%. Interventions included, in order; educating all frailty nurse practitioners, amending the daily patient list to include a separate column to prompt ticking if a falls leaflet was given, and notifying all frailty consultants to consider including “falls leaflet” as part of their post-take management plans.

Conclusion

Having a paper information leaflet can be invaluable to patients as it allows them to go away with concrete bits of information that they can always refer back to. This ensures that elderly patients do not face the risk of forgetting any advice given to them verbally during a consultation and written communication would only help to reinforce this instead. In future, it may be helpful to identify if there are reduced rates of re-admission to hospital in patients discharged with a falls leaflet compared to patients discharged without one.
92 Clinical Frailty Scoring Is Crucial For the COVID-19 Era and Beyond
Authors: White L , Tyler A , Samji A
Published: March 2021

Introduction

The COVID-19 pandemic placed a new focus on provision of clinical resources. With high mortality and limited capacity; appropriate decisions to escalate to critical care were vital for just resource allocation but also to prevent harm where interventions would not change outcomes. NICE guidance highlighted Clinical frailty scoring (CFS) as central to the decision-making process. 1, Despite initial criticism, recent evidence has confirmed increasing CFS as an independent risk factor to inpatient mortality in COVID-19.2 We conducted a quality improvement project with the aim of improving CFS documentation at the Royal Free Hospital.

Methods

We reviewed the notes of 71 inpatients over the age of 65 years from 6 wards on 08/05/20–12/05/20 for both a CFS score documentation and clear treatment escalation plan at time points of initial clerking, post-take and following ward admission with an audit standard of 100%. We developed teaching sessions, promoted the CFS mobile application, developed a post-take sticker and an elderly medicine ward admission proforma. We re-audited 66 inpatient notes from the same 6 wards from 25/06/20–07/07/20.

Results

Documentation.of CFS improved from 7% to 17% for clerking and post-take and from 13% to 24% on the ward admission. The number of patients with treatment escalation plans was 50%.

Conclusion

CFS is crucial for the COVID-19 era and beyond. We have demonstrated that increased awareness improves use of CFS, though it is not yet being widely used in escalation decisions. 1. Covid-19 Rapid guideline: Critical Care in adults. NICE guideline [NG159]: https://www.nice.org.uk/guidance/ng159 Accessed July 2020 2. Hewitt J et al (2020): The effect of frailty on survival in patients with COVID -19 (COPE): a multicentre, European, observational cohort study; The Lancet: https://doi.org/10.1016/ S2468–2667(20)30146–8.
95 Lack of Evidence for Reduced Efficacy of Medical Therapy for Heart Failure in Older Adults
Authors: Cox-Smith A , Cooper T , Punjabi P , Barton C , Levy S , Plymen C , Cole G
Published: March 2021

Introduction

There are almost a million people with heart failure (HF) in the UK; the incidence increases sharply with age. Older adults receive less evidence-based therapy with few trials specifically examining therapeutic efficacy in older age groups representative of a contemporary UK HF population. Concern that efficacy is less in older adults may underlie under-prescription. With important recent advances in HF therapy, we reviewed the contemporary evidence base for any signal of different efficacy in older adults.

Methods

We reviewed recent RCTs of medical therapy for heart failure alongside meta-analyses updated with recent therapies including Angiotensin-Neprilysin inhibitors and SGLT2 inhibitors. For those trials in which effect size was presented for age subgroups we compared the effect size.

Results

Of 68 randomised controlled trials, 10 presented effect sizes for different age groups. The median average cut-off between younger and older age groups was 66 years (IQR 65 to 72.5 years) and the highest cut-off used was 75 years. The median hazard ratio was 0.77 (IQR 0.67 to 0.80) for the younger age group and 0.76 (IQR 0.73 to 0.88) for the older age group. In 8 of the 10 trials, the effect size in the oldest age group was statistically significant on its own including Sacubitril-Valsartan and Dapagliflozin.

Conclusion

When considering the medical therapeutic armamentarium for heart failure as a totality, there is no evidence it is any less effective in older adults than younger adults. The recent Zannad et al cross-trial analysis supported this showing significant additional life years in the patients over 80 years on HF therapy. Whilst there may be practical and frailty-related reasons for not prescribing life-prolonging therapy, the proportional survival benefits of these medications is similar in older adults. This should be utilised where practically possible and discussed with patients when making an informed choice.
98 Rationality of Hypnosedative Use in Seniors in Acute Care: Outputs of the Inomed and Euroageism Projects
Authors: Antonenko O , Zelinková A , Halačová M , Grešáková S , Brkic J , Fialová D
Published: March 2021

Introduction

Insomnia is a frequent problem in acutely hospitalized older adults, particularly in those suffering from polymorbidity and treated by polypharmacy. The aim of our study was to describe the prevalence of insomna and patterns of inappropriately prescribed hypnosedatives in acutely hospitalized older patients in the Czech Republic.

Methods

438 patients (≥65 yrs) acutely hospitalized at 3 geriatric clinics (Brno, Hradec Králové, Praha) in the Czech Republic underwent a comprehensive geriatric assessment (CGA) using the EUROAGEISM H2020 assessment protocols. Descriptive statistics was used to determine the prevalence of insomnia and use of hypnosedatives. Explicit criteria of potentially inappropriate medications (PIMs), mainly 2019 Beers criteria and 2015 EU(7)-PIM list were applied to determine inappropriate patterns of hypnosedatives use.

Results

16.9% (N = 74) seniors had diagnosed insomnia in their medical records, but 34,6% used hypnosedatives in the evening or at night (e/n). 13.8% reported e/n use of drugs aggravating insomnias (particularly beta-blockers- 6.4%, diuretics-2.5% and theophylline- 2.1%). Most frequent hypnosedatives used were: antipsychotics e/n (18.5%), Z-drugs (16,2%) and benzodiazepines e/n (BZD, 14,2%). Non-geriatric doses were determined in users of Z-drugs (10.5%) and sedative antidepressants e/n (1,8%), longer than recommended geriatric duration of therapy has been described for Z-drugs (5.9%,>1 month), BZDs e/n (5,3%,>1 month) and sedative antidepressants e/n (3,3%, >6 months). In total, 1PIM was prescribed to 7.5% of seniors (N = 33), 2PIMs to 2.5% and 3PIMs to 1,1% of seniors. Combination of hypnotics and other sedative drugs was documented in 5.9% of cases.

Conclusion

Inappropriate patterns of hypnosedative use in acutely hospitalized seniors in the Czech Republic at geriatric clinics were found particularly in excessive indication of antipsychotics e/n, inappropriate dosing of Z-drugs and long-term use of BZDs e/n. Supported by: InoMed project (reg. No: CZ.02.1.01/0.0/0.0/18_069/0010046, 2019–2022), EUROAGEISM H2020-MCSF-ITN-764632 project, PROGRESS Q42 Faculty of Pharmacy, Charles University, SVV 260417.
102 Online Supportive Conversations & Reflection Sessions [OSCARS] with Care Home Staff Following A Resident’s Death: Improving Coping Mechanisms, Team Cohesion and Communication
Authors: Hockley J , Johnston L , Watson J , Shenkin S D
Published: March 2021

Introduction

COVID-19 Trauma Guidance suggests opportunities for structured, time-limited discussions about challenging experiences should be offered. It is unknown if such discussions can be effectively delivered online by palliative care specialists to support care home (CH) staff in relation to death/dying. Funded by Scotland’s Chief Scientist Office COVID-19 “rapid research” fund, online OSCaRS is being piloted.

Methods

Fortnightly OSCaRS delivered to small groups of CH staff via a secure online platform in three local CHs over 10 weeks. Sessions are digitally recorded. The shortened version of the Chesney coping self-efficacy questionnaire is completed by all staff pre/post. Additional post-study questions asked of OSCaRS participants and in-depth staff interviews will be undertaken (n = 10). Thematic analysis of the recorded sessions and interviews will be undertaken and related to the staff questionnaire and context of each CH.

Results

New learning on the feasibility and acceptability of providing OSCaRS to frontline staff. The benefit of OSCaRS to CH staff coping mechanisms, team cohesion and communicaton with relatives during the COVID-19 pandemic will be presented. Initial results show that OSCaRS are feasible, valued by all care home staff and support staff in coping with the challenges of COVID-19/.

Key Conclusions

The analysis will inform future practice, and an Implementation Guide for OSCaRS in CHs will be produced. Key learning on the potential for online support in relation to death/dying during the pandemic and beyond will contribute to future education, training and staff wellbeing resources. It will also inform the role of such sessions in developing individual coping mechanisms and team working alongside communication with relatives during lockdown.
104 Assessing for Delirium in A District General Emergency Department—Why are We Failing and How can We Improve?
Authors: Pickard J , Morris R , Crawford I , Mansi R
Published: March 2021

Introduction

Delirium is among the most common of medical emergencies with a prevalence of 20% in adult acute general medical patients. Despite this delirium is underdiagnosed and treatment is variable. Assessment of delirium is missed or carried out unreliably in EDs.

Methodology

Using the Model for Improvement, we developed a driver diagram to plan our project. Assessing whether patients over 65 years old were assessed for delirium during their visit to the ED using a validated tool over a 6-month period. Evaluating the impact of our interventions using annotated run charts. Exclusion criteria—GCS under 13, NEWS2 greater than 5.

Aim

Identify current performance of delirium assessment in over 65 s in Weston General Hospital ED and improve to 100% of over 65 s screened. Assess whether this has been communicated in the discharge summary.

Results

Baseline data showed 22.2% (4/18) of patients meeting inclusion criteria were screened for delirium. We implemented multiple interventions over a 2-month period—discussing at ED handover, hospital wide email, presentation at grand round and displaying a poster in the ED. In the 6 weeks after the interventions were implemented there was increase to 45.4% (15/33) of patients over 65 screened. Delirium/cognitive impairment identified in 42.5% (48/113) of patients screened. This is higher than the national average of hospital admissions therefore it is likely people screen those who display signs of delirium. Cognitive impairment communicated in discharge letter in only 29.4% (33/113) of all patients.

Conclusion

There has been a great improvement in delirium screening. However, we did not meet our target of 100% of patients being screened. Interventions currently being implemented—addition of SQID tool to minors clerking document, addition of compulsory tick box delirium question on all discharge summaries. Further data will be collected to assess effectiveness of these interventions.
105 Beyond the Bleep: Exploring Alternate Methods of Communication in the Multidisciplinary Team to Facilitate Efficient Discharge
Authors: Harcourt H , Hewertson E
Published: March 2021

Introduction

On the surface discharging a patient seems a simple a simple process, but delays due to coordination and communication in preparing medication, transport and discharge summaries are all to common. This results in delayed discharge, which is unfair on patients and their families, adds to the risk of hospital acquired infection and increases NHS expenditure and bed pressures. This quality improvement project investigates alternate systems for coordinating this process to make it more efficient and easier for the relevant stakeholders, with the added advantage of being “bleep free” as is the Health Secretary’s target for 2021.

Method

We started with process mapping and summarising the challenges faced by stakeholders in the current system, which uses bleeps for communication across six older people medical wards and ten medical teams. We progressed to iterative PDSA cycles using Medxnote for one medical team across all wards and then Microsoft Teams on one ward with ten medical teams. New process maps for each were created and circulated to stakeholders to explain the roles and responsibilities of each team.

Results

Both Medxnote and Microsoft teams subjectively made communication easier. However, Medxnote was hampered by the inability to have a three-person conversation and the required use of personal phones. Microsoft teams overcame these obstacles and was able to demonstrate objective improvements with a 42% increase in medication screened before 1 pm and 72% increase in medications prepared on the day of discharge, suggesting better prioritisation. Team feedback was that it decreased workload, made team members more accessible and minimised interruptions to working day.

Conclusions

The initial PDSA cycle suggests Microsoft teams is a promising tool for improving the discharge process and aiding bleep free communication amongst members of the multidisciplinary team. The next step will be a trial across all wards with all teams.
109 Improving Escalation and Treatment Plans in the Borders General Hospital (BGH) During COVID-19
Authors: Ralston K , Campbell A , Alcorn G
Published: March 2021

Topic

Clear escalation and treatment plans created in discussion with patients are crucial to managing patients safely and appropriately. Our goal was to introduce a standardised, easily identifiable document for this purpose, with an aim of 90% of medical inpatients having a clear escalation plan discussed and documented.

Intervention

We developed a Treatment Escalation Plan (TEP), raised awareness via different platforms and delivered teaching for staff. For baseline and subsequent data collections following interventions, we reviewed the notes of twenty random medical inpatients for decisions regarding escalation, patient involvement in decision making including capacity and specific interventions considered. We also included time taken to find information; documented patient/family discussions and whether a TEP was present. We collected qualitative feedback from staff.

Improvement

After introduction, TEP was present in 35/60 patients (58%). Improvement was demonstrated across all measured domains when a TEP form was present: escalation decision (no TEP 80%, TEP 100%), discussion with patient/relative (no TEP 4%, TEP 85%), capacity decision regarding escalation (no TEP 52%, TEP 91%), decision on specific interventions (no TEP 12%, TEP 94%), mean time taken to find information (no TEP 84 seconds, TEP 34 seconds). Qualitative feedback from staff was positive, particularly the inclusion of specific care decisions beyond “DNACPR”.

Discussion

We felt it was critical to develop a TEP to ensure appropriate decisions are made and clearly documented for medical inpatients, especially in light of COVID-19. In patients with a TEP completed, we observed improvements in all domains, particularly in the involvement of patients/relatives in escalation decisions, which is key to delivering patient-centered care. Implementing a new system in a pandemic had challenges, such as continuity of staffing, however feedback was uniformly positive. This is an ongoing project that will continue to promote TEPs to improve patient care.
110 A Single Centre Study on the Thirty-Day Hospital Reattendance and Readmission of Older Patients During the SARS-CoV-2 Pandemic
Authors: Mooney C J , Hone L , Majid M , Cai J , Mieiro L , Fink D L
Published: March 2021

Introduction

Hospital and social care suffered major alterations during the SARS-CoV-2 pandemic in the UK. Older adults were disproportionally affected by routine care disruption. To our knowledge, no data has been published so far on the impact of service disruption on 30-day readmission.

Methods

We performed a retrospective observational study of all patients admitted to a single east London hospital with laboratory-confirmed or clinical diagnosis of COVID-19 between 16th March and 6th April 2020. Older patients were defined as aged 80 years and over. Readmission was captured within 30 days of discharge. Comparator defined as the same period in 2019. Descriptive statistics were used.

Results

Three hundred and ninety-three patients were included. The majority survived to discharge (69.7%). Positive laboratory testing was similar between older and younger patients (85.7% vs 84.7%, p = NS). Mortality was significantly higher for older patients on index presentation (60.2% vs 20.3%, p < 0.001). Length of stay was also significantly longer for these patients (median 9 vs 7 days, p = 0.00694). The readmission rate for the 274 individuals discharged after index admission was 11.3% (n = 31). Amongst older patients, readmission rate during the study period was slightly higher than the same period in 2019 (17.9% vs 14.8%, p = 0.36). The median time interval between discharge and re-attendance was 8 [1–29]days. All re-attending older patients were re-admitted, whereas 54.2% of younger patients were sent home directly from the emergency department. Only 1 of the 31 patients re-attended because of insufficient social care.

Conclusions

Our data shows that readmission rates in the older population of East London during the SARS-CoV-2 pandemic were largely similar to non-pandemic periods. During this period, readmission rates appear to have been driven by clinical rather than social imperatives. This suggests that adapted social care services performed well and should be reinforced for future surges.
111 Tripper: Trying to Reduce Inappropriate Prescribing in Patients Who are Elderly and At Risk of Falls
Authors: O'Kane A , McGarry N , Baillie J , Plumb R
Published: March 2021

Background

Falls in older adults are common, and a major cause of mortality and morbidity. Polypharmacy is associated with a greater number of falls and is prevalent but preventable. The American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication (PIM) Use in Older Adults are used worldwide. This project focused on Table 3 of the 2019 Beers Criteria which recommends an explicit list of PIMs to be avoided in older adults with a history of falls.

Aims

To increase documented discussion about PIMs on discharge letters for elderly patients at risk of falls over a 6-week period.

Method

A retrospective review was undertaken to define baseline data on falls, PIMs and documented discussion of PIMs on discharge letters. Stickers for Kardexes were introduced to highlight PIMs for review. A table documenting discussion of PIMs was incorporated to discharge letter templates. Data was then collected on falls, PIMs and documented discussion of PIMs on discharge letters over a 6-week period. Results: Of patients discharged over 10 weeks, 44% had a history of falls. Of patients with a history of falls, 73% were taking at least one PIM pre-admission. Following intervention, the median percentage of discharge letters with documented discussion of PIMs increased from 4% to 30%. Following intervention, there was a greater average reduction in prescribed PIMs on discharge in patients with a history of falls.

Discussion

We confirmed a significant burden of falls and PIMs in our patient population. QIP intervention increased documentation of PIM discussion and reduced the volume of PIMs prescribed on discharge. Communicating PIM discussion on discharge letters encourages deprescribing; informs primary care and future admissions; and promotes patient centred decision-making in this important risk area. Further work includes collecting feedback from primary care and introducing a PIMs review table to discharge letter templates throughout the hospital.