bluuebunny/crossref_metadata_2025 huggingface dataset:
210 Nursing Home Residents in Acute Hospital – a Targeted ANPc Program to Improve Care
Authors: Noonan Claire , Ryan Dan , Coughlan Tara , Kennelly Séan
Published: September 2019

Background

NHR are the frailest group of older people and require a gerontologically attuned approach to combat multiple challenges presented to the practitioner. The in-reach ANPc liaison service aims to confront such challenges, by providing comprehensive gerontological input to all nursing home residents admitted to hospital under all specialities medical, geriatric, and surgical.

Methods

This service commenced in September of 2018, working 9-5 Monday to Friday with limited leave cross-cover. All nursing home residents are reviewed by a Gerontology Advanced Nurse Practitioner candidate. Each patient received comprehensive geriatric assessment (CGA) with recommendations for care. All had follow up 2 weeks after discharge in telephone review clinic.

Results

118 nursing home residents were admitted for acute care in the study period; 96/118 (82%) were reviewed by the ANPc. 16/118 (14%) were discharged prior to review and 6/118 (5%) died within 24 hours of admission. All other patients were reviewed within 72 hours.

All assessed residents had >1 recommendation for intervention to enhance care following CGA:

Interventions included 31% (30/96) undiagnosed delirium identified and management advice given. 21% (20/96) had recurrent falls work up and advice. 27% (26/96) had recommendations and changes to admission medications. 37% (36/96) referrals to other HSCP therapy disciplines for complete holistic care. 11% (11/ 96) had advanced care planning regarding future illnesses. 13% (13/96) had palliative care advice and referral to community palliative care.

Follow up telephone review clinics have further resulted in reduced readmission rates through liaison with NH staff post-discharge.

Conclusion

The high complexity of this cohort of patients requires a timely, comprehensive gerontological approach in order to provide holistic care. They require a clearly defined approach to enhance care and minimise the need for unnecessary hospitalisations.
216 Integrated Day Hospital for Older Persons in a Primary Care Centre
Authors: McGrath Fiona , Ronayne Sarah , McHugh Karen , McDonnell Mary , Muataz Elnsari , O’Malley Tom
Published: September 2019

Background

To progress with integrated care, for older persons, it was proposed to establish a Day Hospital in a Primary Care Centre. Population data for Co Mayo shows the percentage of those over 65 years, (17.6%), to be significantly higher than the national average

In 2018 there were 39,092 attendances to the Emergency Department and approximately 500, per month, were over 75 years.

The aim was to develop a pathway from the Emergency Department to the Day Hospital for those 75 years and over who had experienced a fall. Additionally, this included an Early Supported Discharge for hip fracture patients.

Methods

The Day Hospital was operational 1 day per week with an allocation of funding for a Consultant, Occupational Therapist and assigned Project Manager.

Holter and Blood pressure monitoring equipment was purchased.

The Home First Team were reassigned to the front door of the hospital and worked with a cANP and a Medical Registrar.

A weekly multi-disciplinary forum, inclusive of all stakeholders, developed working relationships, built a shared vision and standardised the approach for the patient cohort.

Frailty training was provided specifically to Emergency Department staff.

Results

The Home First Team saw 541 patients (Jan-Apr 2019) and in collaboration with the Geriatrician streamed those suitable for management to primary care.

The Integrated Day Hospital, 1 day per week (Jan-Apr 2019) delivered 55 new assessments plus follow-up appointments.

Patient feedback is very positive and specifically highlights ease of access in primary care.

Conclusion

Establishing a Day Hospital in a Primary Care Centre is an innovative approach and shifts the focus of intervention from acute to primary care. The location is ideal due to a range of disciplines on site, PHN, Dietetics, Psychiatry

This is the initial phase, with some pathways in place, and the overall aim is to provide GP access to rapid assessment in Primary Care and thus ensure hospital avoidance where possible.
225 Assessment of Well-being after Stroke
Authors: Donaghy Lisa , McAteer Claire , Morrison Laura , O'Connor Marie , Dolan Eamon
Published: September 2019

Background

Studies have shown that people who have had a stroke are more likely to experience a lower sense of overall well-being, including cognitive impairment, mental health issues, and physical function, than similarly aged people1. Cognitive impairment and memory dysfunction following stroke diagnosis can significantly impact patients’ quality of life2. The aim of this study was to identify how stroke has affected patients at a university teaching hospital stroke clinic in terms of memory, mood and how they are managing at home.

Methods

Thirty anonymous patient questionnaires were completed at a stroke clinic in April 2019. 100% response rate was obtained. Questions included how patients found their mood and memory, and how they were managing at home following their stroke diagnosis.

Results

50% of respondents reported having memory difficulties post-stroke. 57% described low mood since their stroke. 43% required additional help following discharge home, with 69% of this extra help coming from family support. 13% felt they need more help at home than they currently have, with one of these four respondents awaiting a home care package. 20% of patients received further rehabilitation as an outpatient on discharge.

Conclusion

This study highlights significant concerns from patients following stroke with regard to their memory and mood. This emphasises the importance of formal assessment of mood and memory both during admission and on an ongoing basis post discharge. A significant proportion of patients required additional help at home with family members providing the majority of this support.
239 Setting Bones and Getting Home: The Impact of a New Orthogeriatric Service
Authors: Murphy Robert , Reddin Catriona , Dempsey Aoife , Kissane Bláithín , Waters Ruairi , Walsh Thomas , O'Keeffe Shaun , Mulkerrin Eamon , Robinson Stephanie , Egan Ciara , Byrne Fergus , O'Donnell Martin , Murphy Colin , Canavan Michelle
Published: September 2019

Background

Orthogeriatric services have been shown to improve quality of care for older patients post hip fracture and have an impact on length of stay (LOS), both acutely and in the rehab setting(1) but other key performance indicators (KPIs) have not been examined in detail.

Methods

Data was prospectively collected on all hip fracture patients seen by the Orthogeriatric service from Aug 2018-Feb 2019 and was retrospectively compared with patients admitted with hip fractures from Aug 2017-Feb 2018. We examined KPIs including LOS on the orthopaedic ward, rehab admissions, rehab LOS, new nursing home (NH) admissions. We compared the proportions discharged directly home instead of to convalescence, and conducted a preliminary cost benefit analysis.

Results

Similar numbers of patients were seen in each time period (n=146 v n=139). Mean reduction in LOS on the orthopedic ward was 3.5 days (15.5 days vs 19 days). The proportion of patients admitted to rehabilitation increased from 8.8% to 17.5% (p = 0.02). Patients got to rehabilitation faster and for those patients who availed of rehabilitation they had significantly shorter total length of stays (51.1 days vs 71.6 days, p=0.029). Fewer patients went to convalescence. Although not statistically significant there was a trend towards an increased proportion of patients discharged directly home (32.7% to 43.6%) and less new nursing home admissions (6.8% vs 8.4%). A cost benefit analysis incorporating shortened acute and rehab LOS and a reduction in spending on convalescence resulted in a projected saving of €480,390 over a six month period.

Conclusion

Introduction of OrthoGeriatric services has improved care for older people with hip fractures and has resulted in positive improvements to KPIs, resulting in meaningful improvements in clinical outcomes for patients in a cost effective manner. Monies saved should be redirected into further developing orthogeriatric services.
240 Assisted Decision Making (Capacity) Act 2015: Embracing the Paradigm Shift
Authors: Walsh Mary , Lawlor Aideen
Published: September 2019

Background

In a conference 2018, Senator Kelleher said she concurred with the statement describing ADMA “…. as a paradigm shift…a major, major culture shift which has yet to work through our societal systems….”(1) In 2016, a senior and manager speech and language therapist (SLT) won the Dementia Elevator Innovation Award with the project “Empowering Persons with Dementia to Become More Active Participants in Decision Making Related to Their Present and Future Needs”. The IASLT Position Statement on the role of the speech and language therapist (SLT) in assessing Capacity and Facilitating Understanding to Support Decision Making for Adults with Communication Disabilities 2017 names training others in assisted decision making as a key SLT role. Talking Mats (TM) (2) may help address some training issues outlined. TM is discussed in NICE-Capacity Guidelines 2018. The Phase 1 project outlined recommends progression to Phase 2.

Methods

In 2018, the senior SLT trained SLTs working professionally with people with dementia across different service settings. They made a prior commitment to attend and complete the course and to trial TM with people with dementia.

Results

The Phase 1 report Dec 18 contains 16 brief case studies. Some initial findings: Facilitates strengths rather than deficits.Helpful for assisted decision-making when listeners are trained.Pictures help maintain attention and aid comprehension.Pictorial record of photographed TM viewed very positively, particularly for meetings.Video recording sessions, with consent, greatly enhances reflective practice.It helped address the unmet needs of one person with dementia who presented with responsive behaviour.

Conclusion

Talking Mats was strongly endorsed by all participants. Recommendations in Phase 1 report 2018 included progressing to Phase 2 i.e. training the six SLTs to become TM trainers and commence cascading through the system. We are currently awaiting funding approval.
244 Point Prevalence of Frailty and Confusion Exceeds the Capacity of a Single Ward - Specialist Geriatric Wards to Lead Best Practice
Authors: O' Donnell Desmond , O'Mahony Anne , O' Donoghue Alice , McMahon Clare , Doyle Marie , O' Gorman Millie , Mulcahy Riona , Pope George , Cooke John
Published: September 2019

Background

Our Model 4 Hospital will open a Specialist Geriatric Ward in the coming months. This ward will focus on the provision of evidence-based care to confused and frail older adults. Careful selection of patients who would most benefit from this care will be vital to ensure success. We aim to determine the prevalence of frailty and confusion in our inpatient cohort to determine expected demand on this new service and to inform admission criteria.

Methods

All adult inpatients were screened for frailty (pre-admission status) using the Rockwood Clinical Frailty Scale (CFS). Point prevalence of confusion (combination of pre-existing dementia and incident delirium) was calculated by measuring 4AT scores on all adult inpatients (>16 years of age), with the exclusion of obstetric, paediatric, critical care and psychiatric wards. Eleven wards were visited by a team of six experienced geriatric practitioners during a one-week period in April 2019.

Results

In total, 257 patients were assessed. The median age was 74 years (16-99). The majority were male (54.9 %). 152 patients resided on a dedicated medical ward (59.1%). The point prevalence of pre-morbid frailty (CFS Score ≥ 5) was 39.9%. The point prevalence of confusion (4AT score ≥4) was 24.4%.

Conclusion

Our data show that frailty and delirium are highly prevalent in hospital inpatients. It is not feasible for this number of frail and confused patients to be cohorted in a single specialist area. It is therefore important that each hospital determine admission criteria to identify those at greatest need. Clearly, given the prevalence outlined here, there will be a large number of patients likely to benefit from but unable to access a Specialist Geriatric Ward. These wards therefore need to also serve as exemplars of best practice so that evidence-based care for this vulnerable cohort can be disseminated within an institution.
25 The Post Fall Review- An Opportunity to Intervene for Bone Health
Authors: Lynch Amy , Kachappilly Reshmi , Steen Georgina , Lannon Rosaleen
Published: September 2019

Background

Falls are a common occurrence in Irish hospitals and can result in much morbidity and mortality for our patients. According to NICE guidelines, a multi-factorial falls risk assessment should be carried out for those patients at risk of falling, including assessment of osteoporosis risk and medication review. In practice, the post falls assessment is a golden opportunity to assess Osteoporosis risk and adequate bone protection.

Methods

We compiled a list of patient falls registered on the Datix incident reporting system for our five wards over a three-month period from 13/10/18-15/1/19. We looked at the note post fall from the reviewing doctor and documented whether bone protection was addressed and also whether a known history of osteoporosis was documented. This was done on our electronic patient record system.

Results

A total of 106 falls were recorded during this time period. 87% of falls had a documented review post fall. 83 reviews were by the intern on call and team reviewed in 54 cases, often after the intern. 2 of the notes documented whether or not the patient had a known history of Osteoporosis. There was no mention about the presence or absence of bone protection in any of the notes. 14%(15) patients were on bone protection. 37%(40) were on vitamin D or calcium. 2 patients sustained a fracture in their fall.

Conclusion

This audit highlights that bone protection and osteoporosis risk are rarely being addressed post fall. To improve this we are going to give education on post falls assessment (including evaluating osteoporosis risk and assessing current bone protection or need for bone protection) to incoming intern groups and doctors on teams assessing falls. We will reaudit 3 months after this education to evaluate whether there has been an improvement.
248 An Evaluation of Patient Education Post-Stroke
Authors: Morrison Laura , McAteer Claire , Donaghy Lisa , O'Connor Marie , Dolan Eamon
Published: September 2019

Background

In 2018, 212 acute strokes were diagnosed in our university teaching hospital. Our stroke service is evolving to meet the needs of this growing population. The aim of this study was to evaluate the knowledge patients have about their stroke diagnosis and identify how to improve education given post-stroke.

Methods

Thirty consecutive patients attending stroke clinic completed a questionnaire, including questions regarding aetiology of their stroke, medications started, driving and education received as an inpatient.

Results

The thirty patients were a median of 16 months post-stroke. One had a haemorrhagic stroke, all others ischaemic stroke. Only 33% correctly described the type of stroke they had. 50% correctly identified all the risk factors they had been diagnosed with, including atrial fibrillation, hypertension, hypercholesterolaemia and carotid stenosis.

70% of patients reported receiving education in hospital post-stroke. Of these, 13% received written information. 30% of patients were shown their brain scan and the majority (89%) found it beneficial. 71% of those who did not see their scan would have liked to.

52% reported knowing which medications had been started post-stroke but only 23% of patients listed new medications correctly. 43% of patients felt they did not receive enough information about new medications and 27% reported either sometimes or frequently missing medications.

77% of patients drove before their stroke. 74% of these reported that they were advised not to drive post-stroke. Of these, 35% correctly identified how long they were advised not to drive for. Only 26% of those driving before their stroke had driving advice in their discharge letter.

Conclusion

These results illustrate areas in which we can improve education post-stroke, including ensuring patients receive individualised information about the aetiology of their stroke, risk factors and the importance of new medications. It also highlights the importance of ensuring advice regarding driving is clearly explained and documented.
256 The Experience of a Dementia Diagnosis: Joint Submission from The Irish Dementia Working Group and The Dementia Carers Campaign Network
Authors: Whelan Clodagh , Ryan Kathy , Rowsome Micheál
Published: September 2019

Background

Members of the IDWG and the DCCN have differing experiences of receiving a dementia diagnosis. There is a disparity regarding how the diagnosis is communicated, follow up support and the approach of the clinician making the diagnosis.

To improve practice members of both self advocacy groups supported by The Alzheimer Society of Ireland collaborated with a GP to create a video targeting health care professionals.

The video aims to give an insight into the experience of receiving a dementia diagnosis and support best practice in the moment of diagnosis.

It communicates the lived experience of dementia to health care professionals and aims to inspire person centred communication and an understanding of the supports available to those health care professionals

Methods

1. Members shared their personal stories and gathered qualitative data from their fellow self advocates to create a script for the video.

2. Members collaborated with a GP expert to ensure health care professionals were aware of the supports available to them in making a diagnosis.

3. The video is currently being disseminated through professional groups, media and at conferences such as this

Results

A member of the IDWG and the DCCN will present both the video and their experience of engaging with professionals on this matter.

They will offer quantitative data on presentations and qualitative data on their experience.

Conclusion

This is the first campaign which the groups have undertaken together and the first which targets Health Care Professionals.

As a member of the IDWG (living with dementia) says; `for us receiving a diagnosis is not the end of a journey it is the beginning and you can make a huge difference to how that journey begins.

The audience at the IGS Conference is a critical one for the self-advocates and they would very much welcome the opportunity to present.
260 Recording of Syncope Presentations in Model 4 Hospital - Large Variations in Data Collection Systems
Authors: Ryan Sheila , Atikah Asri Nur , Cunningham Nora , Dooley Trina , Quinn Colin , Peters Catherine , O'Connor Margaret , Lyons Declan
Published: September 2019

Background

Patients with unexplained falls, syncope and dizziness frequently present acutely. There are multiple IT systems in operation across the acute hospital network with varying functionality relating to activity capture. MAXIMS is an electronic healthcare record used to capture attendances in our ED. Within our department a digital patient management system Electronic Patient Management System (EPMS) records clinical information from admission through to discharge. The Hospital Inpatient Enquiry System (HIPE) is the principal national source of discharge information from acute hospitals. We aimed to look at this cohort of patients and compare the clinical data available on each of these information sources used in a Model 4 teaching hospital.

Methods

MAXIMS database was interrogated to examine patients who presented to the ED with the search terms “falls”, “syncope” and “dizziness”. We conducted a review of all patients who met our search terms over two non-consecutive weeks in 2018. For the same period EPMS was interrogated and HIPE data were requested and analysed.

Results

MAXIMS, EPMS and HIPE records over the two-week period captured 190, 104 and 24 patients respectively. Mean age was 62, 75 and 72 years. Of 190 records on MAXIMS, 107 (56%) were not coded on HIPE following discharge. Of these 107 patients, 93 (87%) did not require a hospital admission and 14 (13%) patients self-discharged.

Conclusion

Current available digital systems provide inconsistent information relating to patients presenting acutely with falls, dizziness and syncope. How these conditions are captured electronically can vary between systems due to which parameters are recorded. HIPE stats were lower than Maxims/EPMS which may reflect the fact that HIPE only captures discharge diagnosis as opposed to presenting symptoms. In order to get a clearer picture of these conditions, and for planning purposes, an approach amalgamating the data from all systems into one electronic source would be required.
262 Training and Use of the 4AT by a Multi-disciplinary Team to Screen for Delirium in the Frail Adult
Authors: Ryan Siobhan , Cooney Eamonn , Sayers Karen , O'Reilly Aine , Maher Jennifer , Sayers Karen , Baburaj Binish , Donnellan Christina , Pillay Isweri
Published: September 2019

Background

Detection of delirium risk may improve outcomes. We assessed the prevalence of patients at risk of delirium assessed by a trained interdisciplinary team.

Methods

An interdisciplinary team: dietitian, physiotherapist and speech and language therapist was trained to use the 4AT. Community dwelling patients, identified as frail during triage in a hospital emergency department, were assessed including a 4AT, over a 2 month period. Age, gender, Clinical Frailty Score (CFS), 4AT, Modified Barthel index (mBI), polypharmacy (as defined by 5 or more medications) and presence of hearing or visual impairment were entered onto Excel. Performance of the 4AT was at the discretion of the assessor.

Results

150 consecutive patients were assessed. The mean(SD) age was 83(5.1). Female to male ratio was 1.2:1. Mean(SD) CFS was 5.6(1.0).

29(19%) patients did not have a 4AT performed. 63(42%) patients had a 4AT of 1-3. 16(11%) patients had a 4AT of 4 or greater. 42(28%) had a 4AT of zero. Patients with a 4AT 4 or greater were older, mean(SD) age 86(4.2)years. Polypharmacy was present in 10(60%) patients with 4AT 4 or greater and 40(38%) with 4AT less than 4. 10(60%) of patients with 4AT 4 or greater had hearing and visual impairment. 16(15%) patients with a 4AT less than 4 had hearing and visual impairment. 10(60%) of patients with 4AT 4 or greater had a reduction in mBI. 33(31%) of patients with a 4AT less than 4 had a reduction in mBI.

Conclusion

Interdisciplinary teams can screen for delirium risk in ED. Frail patients at risk of delirium are older, have higher rates of polypharmacy, visual and hearing impairment and functional decline. It is possible to evaluate delirium in ED. Further work is needed to explore the relationship between the 4AT and frailty.
268 Can the Swallow Screening Component of a Frailty Assessment be Used to Reliably Direct Clinical Dysphagia Assessment Referrals?
Authors: Maher Jennifer , Pender Ciara , Sayers Karen , Ryan Siobhan , Cooney Eamonn , O'Reilly Aine , Donnellan Christina , Pillay Isweri
Published: September 2019

Background

The prevalence of dysphagia rises with age. It is associated with increased dependency and mortality (Smithard, 2016).

The Irish Association of Speech & Language Therapists (IASLT) only supports swallow screening by trained nursing staff post stroke in acute care settings. Further research is required to establish its use with other clinical populations (IASLT, 2016).

This study was performed to evaluate the use of a swallow screening tool by an interdisciplinary integrated team to identify frail older patients who require a clinical dysphagia assessment.

Methods

This was a prospective cohort study (N=177) of patients admitted through an acute hospital emergency department, between November 2018 and February 2019, 70 years or older, in an acute setting, who were identified as frail based on the Variable Indicative of Placement.

The number of patients referred to SLT due to a positive swallow screen on CGA, conducted by a trained interdisciplinary team was compared with the number referred by the patient’s primary team.

The criteria for dysphagia positive score was to answer yes to any of the swallow screen questions, which were based on risk factors for dysphagia.

Results

Of 177 patients, 47 (26%) screened positive for risk of dysphagia by the interdisciplinary team. Eight, who screened negative for risk of dysphagia, were referred by the patient’s primary team. One out of eight who screened negative, required a diet modification based on an SLT assessment.

Conclusion

A trained interdisciplinary frailty team can reliably screen for and identify risk of dysphagia. This indicates a potential for use of more standardised swallow screening protocols beyond the post stroke population into a broader cohort of patients.
27 Decision-Making Capacity Assessment: Occupational Therapy’s Contribution within a Multidisciplinary Approach
Authors: Usher Ruth , Stapleton Tadhg
Published: September 2019

Background

Increasing age and life expectancy, alongside the growing incidence of chronic conditions and dementia-related diseases, indicate more older individuals are likely to experience challenges regarding decision-making capacity. In Ireland, the Assisted Decision Making (Capacity) Act 2015 provides a statuary framework for adults who are experiencing difficulties with decision-making. This legislation has significant implications for all who work in health and social care, especially those working with older adults. An online survey was conducted to explore occupational therapy practices regarding decision-making capacity assessment and factors impacting on engagement in this area.

Methods

Occupational therapists in Ireland were invited to participate in a cross-sectional online questionnaire.

Results

One hundred and seventy-two occupational therapists responded. Most occupational therapists (65.77%, n=98) reported involvement in decision-making capacity assessments, particularly those working with older adults. Occupational therapists were more frequently requested to contribute to assessments of capacity regarding independent living (79.19%, n=118), driving (45.89%, n=67), and financial management (44.44%, n=64). Occupational therapists reported using a combination of approaches to inform decision-making capacity assessment, including interviews, observations and assessments of cognition and functional performance, and emphasised a strength-based approach.

Many participants reported decision-making capacity assessment is more difficult than other aspects of practice and that they are not satisfied with decision-making capacity assessment procedures in their workplace. A large majority (91.86%, n=113) reported occupational therapists would benefit from additional training and practice resources for decision-making capacity assessment.

Conclusion

The study confirms that occupational therapists have a role to play in assessment of decision-making capacity assessment, particularly regarding independent living. However, the recommended approach to assessment should include all appropriate multidisciplinary team members. There is need for further education, resources and guidelines for occupational therapists and other healthcare professionals to better guide decision-making capacity assessment.
271 Introducing a ‘Do Not Attempt CPR’ and ‘Treatment Escalation Plan’ Form to Improve Patient Care and Decision Making
Authors: O'Keeffe Hannah , Smyth Hannah , Al-Shawee Nora , Tacheva Asya , Bradley Maeve , Mulroy Martin , Lynch Olwyn
Published: September 2019

Background

The HSE National Consent Policy recommends health care professionals ‘develop specific mechanisms for the documentation and dissemination of decisions relating to resuscitation’. We also felt a need to promote a move away from a unidimensional CPR focus more towards documentation of appropriate and inappropriate care for the individual patient.

Methods

In December 2018 we conducted a baseline study of the quality of documentation of patient resuscitation and escalation plans in our hospital. We reviewed the charts of patients on 4 wards on a single day.

Results

Of 80 patients, 19 had some documentation regarding a CPR discussion. Of those 19 one had been determined at time of an arrest call and one at the time of a deterioration. Only 13 of 19 had some documentation of a discussion surrounding the decision. Only 5 had any documentation of the reasoning behind the decision.

Conclusion

Other hospitals in our hospital group had implemented a `Do Not Attempt CPR' and Treatment Escalation Plan form in the last year. With their permission we used their form as a template to develop a form for use across our hospital .This form is to be readily accessible in an emergency and out of hours, and contains quality information regarding the goals of care for an individual patient. The form is a single page, easily identifiable with a red border and filed inside the front cover of the chart.

We have had the form approved by our Lead Clinicians forum and Hospital’s Resus Committee. To promote the successful introduction of the form we have conducted education sessions across the departments of Medicine, Surgery, Anaesthesia and Obstetrics and Gynaecology.

The form has is currently being printed and will be implemented in the coming weeks. We will be closely liaising with users and reviewing its use following implementation.
278 The Acute Spine Fracture in the Emergency Department; a Retrospective Review
Authors: Thorpe Owen , Beirne Avril , Fox Paul , Nic Uidhir Aoife , Dockery Frances
Published: September 2019

Background

As to who should manage osteoporotic spine fractures presenting to Emergency departments (ED) is sometimes debated. We sought to review practice regarding their management in our institution that might inform a clinical pathway.

Methods

We conducted a search of radiology reports for a consecutive series of thoracic or lumbar spine x-rays ordered by ED team only, i.e. a series of patients whose presenting complaint was a suspected acute fracture. We narrowed search to include terms ‘compression’ or ‘wedge’ or ‘end-plate’.

Results

Over 7 months, there were 1,505 such reports; narrowed search and excluding duplicates yielded 168 patients of whom 84 had a fracture. We looked at the acute management of those >50yrs, excluding one metastatic fracture leaving n=64. Of these, 65% occurred following a fall, 14% on twisting/bending/coughing, 14% spontaneous, 7% unclear onset. ED first consulted orthopaedics for 10 cases, neurosurgeons for 2, physicians for 18. A total of 21 were discharged from ED (5 having speciality review pre-discharge). A further 11 were sent home from ED with fracture diagnosis made only when x-ray subsequently reported. Of those admitted, 28 went to physicians with consult to surgeons in 39%, 2 went to orthopaedic surgery, 2 to other specialists. Admission was complicated by pressure ulcer in 13% (4/32), pneumonia in 13%. Overall 24/64 (38%) went on to have MRI/CT (mainly admitted cases). At least 12 were managed with a brace (all records not available). N=7 (11%) had later vertebroplasty. More than half had no documented osteoporosis treatment plans nor GP instruction to address.

Conclusion

Care of spine fractures presenting acutely varies; a high proportion managed by ED solely. Whether outcomes vary as a result is not answered by this audit but there is a need for a pathway to inform best practice. Osteoporosis is inadequately-addressed in this high risk group, highlighting need for fracture liaison services in post-acute management.
285 Inpatient Management of Medications for Parkinson’s Disease
Authors: Doyle Kate , Jonsson Agnes , O'Sullivan Ciara , Gallagher Paul
Published: September 2019

Background

Medication errors during unplanned hospital admissions are common in Parkinson’s Disease, often involving late or missed doses. These errors can result in serious complications and loss of function in these patients. Several Parkinson’s Disease networks and associations have run campaigns aiming to improve medication administration in hospital.

Methods

We reviewed the medical notes and medication charts of 20 patients with Parkinson’s Disease admitted through the Emergency Department. Medication charts were reviewed to assess for levo-dopa containing medications. We assessed whether medication dosing and timing was accurately recorded, if medications were administered on time, and if self-management of medication was considered if the patient was capable during the first 48 hours of admission. We measured our findings against standards from NICE guidelines and Parkinson’s UK.

Results

Only 9 of 20 cases had the times and doses accurately documented on admission. An average of 2.7 doses/patient were missed or delayed in the 48 hour period. Of 152 total doses, 54 (35%) were missed or late. Only 3 out of 20 patients received all their medications on time. Only one out of 20 patients had a documented order to be allowed to self-manage their medication.

Conclusion

Medication errors and omissions during unplanned hospital admissions in patients with Parkinson’s Disease are unsurprisingly common. Many doctors are unaware of the need to provide alternative routes of delivering levo-dopa for patients with Parkinson’s Disease who are fasting or unable to swallow. Patients with Parkinson’s Disease are not being empowered to manage their own medication during hospital admission. Educating doctors on the importance of reducing these medication errors, and the existence of the OPTIMAL Calculator to convert the patients’ usual medications to alternative preparations, is imperative to improve inpatient management of patients with Parkinson’s Disease.
286 Predictors and Outcomes of Older Persons Attending the Emergency Department of a Large Acute Dublin Teaching Hospital
Authors: O'Shaughnessy Íde , Briggs Robert , Timmons Suzanne , Cunningham Conal
Published: September 2019

Background

An emergency department (ED) visit is often considered a sentinel event for an older person due to elevated risks of deleterious outcomes. This prospective cohort study explored factors associated with disposition post ED index visit and unscheduled 30 day revisit.

Methods

Consecutive ED attendees aged ≥70 years, and Manchester Triage System 3-5, in a 6-month period, were eligible for inclusion. Participants underwent an interdisciplinary assessment by a Home FIRsT (Frailty Intervention & Response Team) member. Logistic regression analyses were performed to identify factors predictive of admission post ED index visit and unscheduled revisit. Predictive validity of frailty instruments were performed using receiver operating characteristic (ROC) curves

Results

1,156 ED attendances were included - 59% were female; median age was 80 years; 66% were discharged home post index visit; 17.8% had an unscheduled ED revisit within 30 days. Age and sex did not predict hospital admission. Hospital admission post ED visit was imperfectly predicted by mild-moderate frailty: Clinical Frailty Scale 5-6 (Odds Ratio (OR) 1.83 (95% CI 1.11 – 3.04), p=0.019); ‘Think Frailty’ 3 (OR 1.75 (95% CI 1.07 – 2.85), p=0.025) and 4 (OR 2.32 (95% CI 1.16 – 4.63), p=0.017). Paradoxically, higher frailty scores were not predictive. Cognitive impairment (4AT 1-3) similarly predicted admission (OR 1.62 (95% 1.16 – 2.27, p=0.005), while delirium (4AT ≥4) was the strongest predictor of admission (OR 5.87 (95% CI 3.17 – 10.88, p<0.001). ROC curves of both frailty scales showed moderate ‘diagnostic accuracy’ for admission, but less so for unscheduled revisits.

Conclusion

Home FIRsT operationalised the assessment of frailty and delirium in the ED. Delirium is a strong predictor of admission post ED index visit, more than frailty status. Older persons have a high rate of 30-day unscheduled revisits; however, it is difficult to produce models from patient information available at index visit that can reliably predict unscheduled revisits.
288 Hearing Loss as a Potentially Modifiable Risk Factor in People with Mild Cognitive Symptoms Attending a Specialist Memory Service
Authors: McHale Cathy , Sharkey Jennifer , Coughlan Tara , O’Neill Desmond , Dookhy Joshi , Sheridan Lisa , Kennelly Seán
Published: September 2019

Background

People with mild hearing loss at age 50 are twice as likely to develop dementia increasing to a five times greater risk for those with severe hearing loss. The prevalence of dementia and hearing impairment increase with age. Intact hearing enables cognition, facilitates social interaction and enhances communication. Hearing loss, social isolation and dementia are commonly interwoven. We recently commenced routine audiology screening in our memory service.

Methods

Consecutive patients with mild cognitive impairment attending a tertiary memory assessment and support service were referred for full audiology screening. People were routinely referred on basis of cognitive diagnosis, and not on the basis of perceived hearing loss. Assessment included ENT history, otoscopy, tympanometry, pure tone audiometry and speech audiometry to determine the presence, type and amount of any hearing loss present. This included speech discrimination testing – a functional test to determine processing of 10 phonetically balanced words with 100% being an optimal response.

Results

20 people (12 women), mean age 72.3 (range 57-87) were assessed. The majority had amnestic MCI 18/20 (90%). 9/20 (45%) patients subjectively complained of hearing loss. 7/20 (35%) had history of occupational noise exposure. 12/20 (60%) had occlusion due to ear wax.

Hearing loss identified: Mild 8/20 (40%); Moderate to severe 7/20 (35%); with Normal hearing in 5/20 (25%). High frequency hearing loss was noted in 19/20 (95%). Speech discrimination score was impaired in those with hearing loss: mean 89.4% (range 66-100). 6/20 (30%) received referral for hearing aids.

Conclusion

This study highlights the importance of incorporating an assessment of auditory acuity as part of memory assessment and post-diagnostic care-pathway for people with mild cognitive complaints given the established impact hearing loss has on the future risk for cognitive decline. Hearing loss is frequently unidentified and is a clear modifiable risk factor to promote brain health.
289 Detection of Falls in Older Patients by Medical Professionals on Admission to Hospital: An Audit
Authors: Buckley Emily , Alalawi Mazen
Published: September 2019

Background

A history of a previous fall is one of the best predictors of future falls, increasing its risk 3-fold. The Health Service Executive (HSE) best practice guidelines recommend that all patients aged over 65 years in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and asked about the fall-frequency, context and characteristics. The aim of this audit was to increase falls recognition by medical professionals following the implementation of a falls screening questionnaire into the admission proforma of an acute hospital.

Methods

This was a clinical audit. Data was collected on 29 consecutive patients aged > 65 who were admitted via the emergency department of an acute hospital over a 6 day period. Data on falls was collected using the medical admissions hospital proforma during the first 72 hours.

Following the initial audit, a new proforma containing a falls screening questionnaire (as per best practice guidelines) was introduced and an information session provided on its use. A re-audit of 17 admitted medical patients was then completed over the next 72 hours.

Results

The initial audit highlighted poor assessment of falls with only 3 (25%) patients being screened at admission. 1 (33%) had a fall; described as mechanical. Following introduction of a falls screening questionnaire into the admission proforma, a re-audit showed a significant increase, with 58% of admissions now being screened. Of these, 40% had fallen in the last year: 75% of falls were mechanical and 25% due to other causes.

Conclusion

This audit shows that falls in this patient population was largely unrecognised by medical professionals. Following implementation of a screening questionnaire, significant improvements were made. This audit concludes that implementation of a falls screening questionnaire into the medical admissions proforma is an effective method in identifying falls in older patients admitted to hospital.
290 Are Clients Satisfied with Integrated Care? Enhancing Client Feedback on Discharge from a Domiciliary Based Multidisciplinary Integrated Care Service
Authors: Boyle Nichola , McDonnell Sinead , Balasubramanian Subha , Reynolds Niamh , Geary Niamh , O'Shea Diarmuid , Hession Eilis
Published: September 2019

Background

The Integrated Care Programme for Older People has supported the development of integrated care services at pioneer sites in Ireland, each developed to meet local needs. Patient Reported Experience Measures (PREMs have been used to evaluate user experience in intermediate care in the United Kingdom. This project aimed to evaluate client experience of a domiciliary based, multidisciplinary, integrated care service.

Methods

A qualitative audit of the experience of clients of the Older Persons’ Integrated Care Team (OPICT) was performed. This project was undertaken in conjunction with the Royal College of Physicians of Ireland’s Quality Improvement in Action programme. A feedback questionnaire was designed and distributed to consecutively discharged clients from OPICT from February 2019, providing qualitative assessment for service improvement. The results of feedback from the first questionnaire design are reported.

Results

Twenty OPICT clients received a feedback questionnaire following their final interaction with the OPICT service. Eighteen clients responded: 11 males and 9 females with mean age 81 years. Two male clients did not return the questionnaire (mean age 86 years). In terms of the treatment and advice provided by the team, all 18 clients agreed with statements that they were involved in decision making, treatment was explained in a way that they could understand and was effective and met their needs. All clients responding indicated that they were listened to, treated with dignity and had confidence and trust in the team. All 18 respondents would recommend the service to another older person. Respondents also provided individual comments which all indicated satisfaction with the service.

Conclusion

Older people accessing integrated care delivered in their home reported a positive experience and can provide important information on further service development.
303 Integrated Care Hubs for the Older Person: RIGHT TIME, RIGHT PLACE
Authors: O'Donoghue Alice , MacMahon Clare , Bolger Margaret , Roche Suzanne , Phelan Niamh , Murphy Catherine , Grant Emma , O'Donnell Desmond , O'Mahony Anne , Henin Maged , O'Gorman Millie , Masombo Rudo , Doyle Marie , Hartnett PJ , O'Halloran Adriana , Pope George , Mulcahy Ríona , Cooke John
Published: September 2019

Background

Our Integrated Care Hub has been operating since mid-2017 providing patient-centred multidisciplinary team (MDT) care operating via a number of specialised care pathways. There has been an early emphasis on the response to crisis presentations and with the introduction of the Hub we now have an extensive and organised response to such presentations. We wanted to assess does this system result in earlier referral of the ‘Crisis’ patient to an Integrated Care Hub.

Methods

We performed a retrospective quantitative analysis of data comparing two time-periods January to June 2018 with January to April 2019 (year-to-date). The number and type of MDT contacts were classified into 4 categories: Immediate Crisis (would present to the Emergency Department within 48 hrs if not reviewed), Emerging Crisis (would present to the Emergency Department within 2 weeks if not reviewed), Stable Situation (needs optimisation), Stable Situation (no intervention). Data were extracted from File-Maker Pro.

Results

There were 424 MDT contacts in January-June 2018 compared with 658 MDT contacts in the year-to-date 2019. The number of patients in these time-periods presenting in ‘Immediate Crisis’ was reduced in the year-to-date 2019 - 4.41% when compared to the same time-period in 2018 – 11.79%. There was a similar reduction in ‘Emerging’ Crisis presentations in these time-periods: 15.65% in 2019 vs. 24.29% in 2018. While the patients attending that were classified as Stable Situation (needs optimisation) increased in 2019 compared to 2018 – 66.57% vs. 47.88%.

Conclusion

We can see from our data that the creation of our Integrated Care Hub has resulted in an increased demand for our service, however, interestingly we have found that the crisis patient load has, in fact, decreased. This suggests that we are influencing referral patterns by both recognising and intervening at an earlier stage to manage, stabilise and reverse crisis in these patients in an organised manner within the MDT.
304 ED-FASU: A Novel ‘Front Door’ Multidisciplinary Service Assessing Patients with Falls and Syncope in the Emergency Department
Authors: Bourke Robbie , Rice Ciara , McMahon Geraldine , Cunningham Conal , Anne Kenny Rose , Briggs Robert
Published: September 2019

Background

Patients with falls/syncope/presyncope frequently present to the emergency department (ED) and many that could be managed safely in an ambulatory care setting are admitted for extensive diagnostic work-up.

A pilot intervention commenced in March 2019, with direct access to specialist assessment in the ED for patients presenting with falls/syncope/presyncope, aiming to provide appropriate testing and early diagnosis to reduce unnecessary hospitalizations.

This pilot study assessed the feasibility of embedding this service within the ED, as well as the effectiveness of the intervention in terms of admission avoidance.

Methods

The study was conducted between 25th March and 19th April 2019 in a large urban teaching hospital with a dedicated Falls & Syncope Unit and compared to similar data from March/April 2018.

The core ED-FASU team comprised a consultant geriatrician, specialist registrar in geriatric medicine and clinical nurse specialist.

Inclusion criteria were those of all ages, presenting with falls/syncope/presyncope/dizziness between 0800-1800 Monday-Friday. Patients were reviewed directly from triage or after referral from the ED team.

Results

In total, 203 patients were assessed during the pilot, an average of 10 assessments per day. The median age of those seen was 63 (58.0-67.0) years. Almost one third (57/203) were aged ≥75 years.

After excluding those who were already admitted to the acute hospital and awaiting a bed when seen in the ED (n=29), 24% (41/174) of those seen were admitted to hospital. This compares to an admission rate of 33% (73/223) for the 2018 comparison group (p = 0.045).

Conclusion

This pilot study shows that it is feasible to embed specialist assessment for falls/syncope/presyncope in the ED.

Initial pilot data suggests a significant reduction in admission rates for those seen by this service but needs to be confirmed over a more prolonged assessment period and alongside data on readmission and length of stay.