bluuebunny/crossref_metadata_2025 huggingface dataset:
Tracing the signatures of a quiet Sun nanoflare
Authors: Robinson Rebecca A. , Carlsson Mats
Published: July 2023

Context. Nanoflare-scale reconnection events are difficult to detect, and even when they are detected, it is tricky to reconstruct the details and trigger mechanisms that power them. However, numerical models of nanoflare-scale reconnection can provide context to observations of small-scale reconnection events via the comparison of synthetic observables to observed signatures of the nanoflare.

Aims. We aim to demonstrate how a simulated nanoflare event would look if it were observed by the Solar Dynamics Observatory Atmospheric Imaging Assembly (SDO/AIA) and the upcoming Multi-slit Solar Explorer (MUSE). The goal is to determine the details (if any) of nanoflare-scale reconnection events that could reasonably be captured by current and future instruments.

Methods. We calculated synthetic observables from a quiet Sun simulation of a nanoflare-scale reconnection event, including integrated intensities of Fe IX at 171.073 Å and Fe XII at 195.119 Å. Then, we degraded the synthetic observables to SDO/AIA and MUSE resolutions in order to determine whether the instruments are capable of capturing the details of the reconnection event.

Results. We determine that even small-scale reconnection events in the quiet Sun can be detected by both SDO/AIA and MUSE. In the 171 channel of each instrument, it is possible to discern details of the two bidirectional jets that emanate from the reconnection site. These two bidirectional jets correspond to two different magnetic features undergoing large-angle reconnection with an overlying horizontal field in the corona. In the 193 channel of SDO/AIA, it is only possible to see one set of bidirectional jets, which corresponds to the most energetic reconnecting feature. However, the calculated count rate for AIA 193 is not sufficient for a reliable observation.

Conclusions. Quiet Sun activity is detectable with SDO/AIA and will be detectable with the future MUSE mission. It is possible to detect bidirectional jets with both instruments, which can give context clues as to the mechanisms causing the nanoflare event. The resolution and spectral information of MUSE will give a much more detailed observation of the event, making it much easier to reconstruct a possible trigger mechanism. However, we must be careful in our interpretations of observations when we have limited information, as vastly different physical processes can produce similar observational signatures.
Salivary protein expression profiles of five species of Pentatomidae (Hemiptera)
Authors: Marshall Adrian T , Cooper W Rodney , Walker William B , Wildung Mark R , Northfield Tobin D , Krey Karol L , Beers Elizabeth H
Published: July 2023

Stink bug (Hemiptera: Pentatomidae) development typically requires feeding on a diversity of plant species and various plant tissues. During feeding, stink bugs discharge salivary enzymes with roles in extraoral digestion and countering plant defense responses. Although previous research has described digestive salivary proteins from stink bugs, less is known of the salivary proteins involved in the suppression of plant defenses. We sequenced the transcriptomes of salivary glands dissected from five stink bug species collected from non-crop habitats in Washington: Halyomorpha halys (Stål), Nezara viridula L., Euschistus conspersus (Uhler), Thyanta pallidovirens (Stål), and Chlorochroa ligata (Say). We identified a total of 677 candidate secreted proteins from the salivary glands of the five species. Based on work from other insects, many of the proteins have potential functions in the suppression of plant defense signaling and deactivation of plant defense molecules. We also identified salivary proteins with potential roles in the extraoral digestion of plant tissues, protection from entomopathogens, and deposition of salivary sheaths. This report provides a curation of putative salivary effector genes for further functional analysis.
1566 EVALUATING A NEW DELIRIUM FOLLOW UP CLINIC SERVICE
Authors: Khan D , Ling K T , McNeela N , Janagal S
Published: July 2023

Background

Delirium is common and experienced by 20% of all admissions to hospital1. Studies have shown a link between delirium and development of dementia2 but there are not many services to follow such patients up, post-discharge. A new service has been developed at New Cross Hospital run by Care of the Elderly Consultants with an interest in Cognition.

Methods

A delirium follow up clinic was designed to assess these patients after 6 to 8 weeks from discharge following hospital admission or reviews in Frailty. We set up referral criteria for prolonged or recurrent delirium follow up. The clinic is run by a consultant and a registrar. A thorough history is taken and memory is assessed using the Addenbrooke's Cognitive Examination III or RUDAS. Data was collected and analysed from the clinic and the outcome was fed into Excel.

Results

31 patients reviewed post admission with delirium, with 8 of those having a suspected cognitive impairment. 12 patients were diagnosed with dementia and 6 with Mild Cognitive impairment (MCI). The subtypes were as follows: Alzheimer's (2), Mixed Dementia (2), Vascular Dementia (6), Lewy Body Dementia (1), Fronto-temporal dementia (1). Only one patient had fully resolved delirium with no cognitive impairment. The rest of the patients had a diagnosis of BPSD (Korsakoff's) (1), ongoing reviews (4), cognitive impairment not quantified (6) and pseudodementia/ depression (1).

Conclusion

This service has ensured follow up for patients with delirium and has shown a significant relationship between complex delirium and MCI or dementia. It has provided a medium to diagnose, treat and signpost patients and carers for support with community services. Very few regions have such pathways in place and the services to follow up patients with delirium discharged from health care settings. This service offers quick and comprehensive follow-up for patients with concerns regarding cognition.
1579 IMPROVING DETECTION AND DIAGNOSIS OF DELIRIUM IN ELDERLY PATIENTS ON ADMISSION WARDS WITH THE USE OF 4AT IN A TERTIARY CENTRE
Authors: Sharp A , Gray J , Abraham S , Danbaki E , Hauxwell J , Atkinson M , Headlam J , Ninan S
Published: July 2023

Introduction

Delirium remains under-recognised. We wished to improve recognition of delirium on our assessment wards.

Methods

Data was collected prospectively on two admissions wards between 18/10/21 and 30/01/23 initially weekly, and then periodically to assess for the presence of a 4AT assessment by post take ward round. PDSA 1 -Departmental meeting to raise awareness and creating of an improvement team including doctors and ward managers. PDSA 2 -Teaching ward nurses “How to” do a 4AT and education sessions for nurses on delirium. Online guide on 4AT PDSA 3 -Adding 4AT to the admissions checklist performed by nurses.

Results

On ward A, 4AT completion rates improved from 15.4% to 35% with a step change in completion rates with 6 points above the baseline. On ward B, 4AT completion rates improved from 14.8% to 24.5% with a step change improvement but with wider variability.

Conclusions

Ward teams felt that education and inclusion of the 4AT to the admissions checklist would result in significant improvement. Whilst a statistically significant improvement did occur, 4AT completion rates are still lower than desired and there was still some resistance to completion from both medical and nursing teams. Ward A had a few nurses who took up admission 4AT completion enthusiastically, with strong local leadership from the ward manager. The nursing leadership of the wards changed during the time of the project, and consultant cover was at lower levels than has been the case historically. We have now added 4AT to the “ward metrics” so wards will be measured on compliance. We have launched a trust-wide delirium improvement plan, supported by senior management. We plan for routine electronic collection of 4AT completion rates. In addition, we have designed a delirium care plan to link 4AT assessment to prevention and management.
1596 HOW COULD PRE-HOSPITAL ‘SILVER TRIAGE’ FOR OLDER PEOPLE LIVING WITH FRAILTY BE IMPROVED? – THE VIEWS OF PARAMEDICS
Authors: Teranaka W , Jones H T , Wan B , Tsui A , Gross L , Hunter P , Conroy S
Published: July 2023

Background

Most older people access acute hospital care via ambulance conveyance. The ambulance service provides a key link in the urgent care chain, yet the role of frailty-attuned assessment and care in this context is poorly understood. North Central London Integrated Care System has invested in a pre-hospital programme where geriatricians and emergency physicians support London Ambulance Service: ‘Silver Triage’. We report here on feedback on the scheme from paramedics.

Methods

452 cases were discussed with Silver Triage between November 2021 and January 2023. Paramedics using the service were sent a survey including a free text question on how the scheme could be improved which was analysed thematically.

Results

103 comments were organised into three key themes: 1. Improving access to the service – this included expanding to a 24-hour service, accessible in other areas of London, available to emergency medicine technicians and for people not living in care homes. 2. Improving information about the service – this included education for paramedics on who to refer but also increasing awareness of the scheme in local emergency departments. 3. Improving delivery of the service – this included requests for video conferencing, reported technology issues and frustrations with pathway breakdown following triage. For example, if the agreed plan was not to convey and to support through rapid response or district nurse services, lack of availability led to conveyance to hospital contrary to outcome of triage.

Conclusion

Whilst the Silver Triage scheme has been well received by paramedics, there are clear areas for improvement to ensure sustainable and equitable pre-hospital care for older people living with frailty.
1635 THE INTRODUCTION OF AN OLDER PERSON’S ASSESSMENT UNIT AND IMPACT ON LENGTH OF STAY AT ROYAL BOLTON HOSPITAL
Authors: Cash R , Khan A , Donnelly G , Han-Lim V , Oates R
Published: July 2023

Introduction

Nationally, there have been increased attendances to hospital for older frailer adults. Recommendations from GIRFT and NHS England acknowledge the importance of identifying frailty, and the role that dedicated specialist services play. Best practice indicates when frailer adults receive a Comprehensive Geriatric Assessment (CGA), this reduces patient harm and improves outcomes. Locally in October 2022, Bolton NHS Trust converted an Acute Medical Assessment Unit (AMU) to a 22 bedded frailty unit, the Older Person’s Assessment Unit (OPAU) to provide older frailer adults with early specialist input and review from a dedicated multi-disciplinary team (MDT). The unit is run by three Consultant Geriatricians and a dedicated wider MDT, with links to community partners and when needed preferential admission to Geriatric base wards.

Methods

Data was collated and analysed with set metrics by the Trust’s Business Intelligence Department. Data was compared for the 3 months pre and post inception of the frailty unit. Regular service reviews occur and utilise PDSA cycles to assess interventional change.

Results

The average age of patients pre-intervention was 69, and post intervention was 79.6. Pre-intervention, the average length of stay for patients admitted from AMU to Geriatric base wards was 25.93 days. This reduced to 18.79 days post-intervention. The average length of stay for patients admitted to non-Geriatric base wards was 10.77 days, this reduced to 8.62 days post intervention.

Conclusion

Specialist Consultant Geriatrician and MDT input on a dedicated frailty unit has reduced the average length of stay of patients to all base medical wards assessed, especially base Geriatric wards. This has clear implications on patient flow, and benefits patients and the Trust. We expect this will have a compound and positive effect on patients by reducing the risk of deconditioning and potential development of inpatient harms.
1637 IMPROVING PLANNED CARE IN THE FRAIL AT MORRISTON (IPCF MORRISTON) PHASE 1
Authors: James K , Soppitt D , Davies E , Burberry D
Published: July 2023

Introduction

The pathway for referral to elective perioperative clinic involves frailty screening patients at the point of referral1. This is adequate If waiting times are short. At Swansea Bay 6,458 patients>65 years are awaiting surgery with up to 5 year waits for cholecystectomies. Opportunity to medically optimise patients prior to surgery are lost using a traditional approach. We aimed to develop a screening tool to identify frailty in patients awaiting surgery.

Method

The cholecystectomy list (750 patients) of which 258 were> 65years. Older people were sent a postal questionnaire gaining 96 responses. 58.3% felt their health deteriorated since being referred for surgery. 50% stating they had unmet healthcare needs and 17.5% stating unmet social care needs. Frailty was identified using this questionnaire, telephone interview or electronically by the Hospital Frailty Risk Score (HFRS).

Results

193 patients were successfully contacted utilising an expanded CRANE questionnaire. All patients triggering on HFRS, CFS>4 or any concern on the CRANE questionnaire were offered a clinic appointment. Each interaction was then classified into change or no change in medical management of patients. 92 patients had no interventions, 35 had an intervention following the initial CRANE telephone questionnaire that did not require further input, 31 had an intervention following clinic. CFS>4 identifies 56% of the patients that undergo any form of intervention. HFRS identifies 34% and the CRANE questionnaire identifies 42%. In patients who need a clinic review HFRS identifies 19%, CFS>4 identifies 59% and CRANE identifies 87%.

Conclusion

The CRANE questionnaire is a useful screen for patients on a waiting list who will benefit from an elective perioperative clinic.

Reference

1. Guidelines of perioperative care CPOC.
1660 QUALITY IMPROVEMENT FOCUSSED ON IDENTIFICATION AND MANAGEMENT OF DELIRIUM IN OLDER SURGICAL PATIENTS
Authors: Millington K , Baguneid C L , Pattinson J , Ford H , Evans B , Gordon A L
Published: July 2023

Background

This Quality Improvement project was undertaken at University Hospitals of Derby and Burton. The team comprised a speciality doctor and improvement fellow previously employed as an operating department practitioner (ODP). Senior sponsors comprised a consultant geriatrician and Divisional Nurse Director.

Introduction

Delirium impacts up to 40% of older hospital inpatients and is associated with mortality, institutionalisation and deconditioning. We aimed to increase diagnosis and management of delirium to reduce complications, length of stay and readmissions.

Method

An initial audit measured delirium prevalence using 4AT in patients aged >65 on arrival to the Surgical Assessment Unit (SAU) and 48 hours later. A series of plan-do-study-act (PDSA) cycles then tested small-scale changes to improve delirium practice on SAU. We developed, implemented and iteratively improved 4AT and delirium sections in care plans. We developed and delivered teaching and supporting materials around the PINCHME acronym to SAU staff. 4AT and delirium care plan completion rates were monitored. Staff knowledge before and after teaching was tested.

Results

36% of 111 consecutive emergency surgical admissions audited were likely to have delirium based on 4AT. 5% were coded as having delirium and 19% had delirium documented in their notes. Average length of stay was 7, 10 and 5.3 days for the whole cohort, those with and without delirium respectively. These data convinced SAU managers of need for change. Improvements around 4AT screening were associated with a rise in average 4AT completion rate from 40% to 64%. Completion rates were highly dependent on the improvement team, rising as high as 100% after interventions but falling back between these. Knowledge scores improved from 43% to 92% following teaching.

Conclusion

Improvements correlated with higher delirium screening and detection rates, and staff knowledge improved. Interventions were not sustained. We are now exploring delirium champions as a way of sustaining change.
1580 STRUCTURED MULTIDISCIPLINARY REVIEWS FOR CARE HOME RESIDENTS REDUCE POLYPHARMACY COST-EFFECTIVELY
Authors: Bradburn L , McNair S , Munang L A
Published: July 2023

Background

West Lothian has 17 care homes with 881 residents. General Practitioners (GP) undertake annual review of all residents, including medication review, with variability between practitioners.

Introduction

Multidisciplinary team (MDT) working is the cornerstone of comprehensive geriatric assessment. MDT meetings are an excellent environment for shared learning and discussion. We applied this principle to a 2-year project delivering structured MDT medication reviews of care home residents.

Methods

Funding was secured for a consultant geriatrician (0.5PA for 2 years, £6500 per year) to join the Lead GP, Integrated Care Pharmacist and care home nursing staff in setting up an MDT for each care home. Complex patients were discussed in monthly MDT meetings, focusing on medication reviews. Shared decisions were documented on primary care clinical notes and amendments made to prescriptions. Where necessary, further GP review assessed subsequent impact of medication changes. Annual cost savings were calculated based on the current Scottish Drg Tariff. Qualitative feedback was sought from all members of the MDT.

Results

43 residents from 9 Care Homes were discussed in 11 MDT meetings between Jan-Dec 2022. Average age was 83.3 years (64.9-101.3), 63.4% were females. In total 6 new medications were started, while 87 medications were stopped. The dose was increased in 5 medications but decreased in 37 medications. Total annual savings were estimated at £6657, an average of £155 per resident discussed. Feedback from all members of the MDT was positive, particularly for improving patient care and increasing knowledge and confidence in managing this frail population.

Conclusion

Structured MDT reviews ensured patients were on appropriate medications focusing on improving symptoms and quality of life, in keeping with principles of realistic medicine. The estimated annual savings exceeded the funding invested, making this intervention cost-effective. We plan to scale this up further in Year 2 of this project.
1614 DEVELOPING OUR OLDER PEOPLES LIAISON SERVICE: IS A FRAILTY NURSE LED MODEL THE WAY FORWARD?
Authors: Wells A , Campbell F , MacDonald E , Brown D , McCosh A , Saad I , McInnes C
Published: July 2023

Introduction

‘Older People in Hospital Standards’ (2015) identifies that Older People should have care/treatment in the most suitable settings. In University Hospital Monklands (UHM) a liaison service was provided to frail patients who needed care outside our older people’s wards (e.g. Surgical wards), led by clinicians (Consultant Geriatrician/ specialty doctor) twice weekly with support from Frailty nurses (FN). Patients were referred via multiple routes (email, letter, phone). Our aim was to develop a single point of referral, to increase capacity, be more responsive and FN led.

Methods

We developed the FN workface by recruiting advanced/ trainee advanced nurse practitioners. We developed an electronic referral and Electronic Frailty alerting in October 2022. We provided education/visual prompts about the service and embedded the referral pathway/criteria in the hospital ‘huddle’ and safety briefs. From December 2022, all patients referred were reviewed by a FN.

Results

From December 2022, the number of electronic referrals has increased by 70%. The number of patients who have a recorded clinical frailty score (CFS) has increased from 50 % to 98%. We now have a 5day service, where referrals are seen the same day by FN. We reduced the need for clinician input from 2 sessions/week to 0.5 sessions/week, allowing redistribution of workload. There has been no change in outcomes of discharge planning/rehabilitation/repatriation for patients before and after the change.

Conclusion

The number of referrals made electronically has increased – allows a more responsive service, standardises the pathway and reduces FN time in responding to phone calls/emails. This has increased the number of patients who have a CFS completed. It has released clinician time to deliver care in other parts of the system. Ongoing plans include developing this to be fully FN led and using it in planned care e.g. in preoperative admissions.
1627 DOES HAVING A CLINICAL COORDINATOR IN THE SAME DAY EMERGENCY CARE OLDER PERSON’S UNIT IMPROVE ITS EFFICIENCY?
Authors: Laud M , Penn O , Richardson H , Gould D , Mukokwayarira C , Harris J , Nair S
Published: July 2023

Introduction

The Same Day Emergency Care Older Person’s Unit (SDEC OPU) provides urgent holistic care, complementing acute and community services to deliver comprehensive geriatric assessment. In October 2022, we introduced a new clinical coordinator role with the aim of improving patient flow. Prior to this role existing, one clinician per day was assigned to take referrals alongside reviewing their own patients, without having an overview of the processes and outcomes of the day. The new clinical coordinator role included taking referrals, vetting patients in A&E, assigning tasks to clinicians, leading regular ‘huddles,’ reviewing results, preparing notes and discharge letters, and requesting specialty referrals. The role was introduced to reduce the waiting time of patients within the unit and to reduce waste through the Leeds Improvement Method.

Method

Data was analysed from a 13-week period both before and after the role was implemented, with the main focus being patient length of stay. 454 patients from before the clinical coordinator role was introduced, and 360 patients following its introduction were included.

Results

Mean length of stay was calculated at 5hr 11minutes before the role introduction and 4hr 45minutes afterwards. This reduction in length of stay (LOS) was statistically significant (p=0.015), with a 95% confidence interval where LOS was reduced between 8 and 43 minutes (p=0.0029). The percentage of patients discharged within 4 hours of arrival was 30.4% before the implementation and 36.7% after it. This was not statistically significant (p=0.0593). The percentage of patients discharged over 7 hours after arrival was 19.8% before the implementation and 13.3% after it. This was statistically significant (p=0.0143).

Conclusion

The introduction of a bespoke clinical coordinator role within SDEC OPU significantly reduced patients’ LOS; it has also provided leadership to the team, improved efficiency, and patient experience through the unit.
1613 IMPROVING ELECTRONIC FRAILTY ALERTING IN UNIVERSITY HOSPITAL MONKLANDS: A WHOLE SYSTEM APPROACH
Authors: McInnes C , Moultrie N , Wells A , Campbell F , Macdonald E , Tan E
Published: July 2023

Introduction

Older people with frailty are at risk of adverse outcomes from hospital admission. Early identification of frailty at can help reduce these. The Clinical Frailty Scale (CFS) identifies frailty, is quick to perform and can be done in acute settings. We have a well-established a Frailty Assessment Unit (FAU) which supports comprehensive geriatric assessment (CGA) for older adults with frailty in hospital. We developed direct admission pathway for frail patients direct from our emergency department (ED) to FAU and we needed to ensure that CFS was performed in the ED.

Methods

A training and education programme in CFS was delivered to ED via Frailty nurse practitioners. CFS was embedded in the ED safety briefs and daily handovers. A Frailty link nurse was identified in ED. We implemented an electronic CFS Frailty Alert (eFA) to our electronic Patient Management System.

Results

A direct admission pathway was established in March 2021 and eFA began in September 2021 (delayed due to Covid-19). The number of patients presenting to ED who have eFA added at admission has increased from 4/month to 100/month. This has allowed us to maintain 80% of patients being admitted to FAU (and therefore to GCA) < 24 hours of attendance at hospital. The number of patients who have an eFA recorded in the overall service has also increased.

Conclusion

We improved the number of patients with an eFA in ED and can better identify who needs CGA. We can use eFA as a visual tool for site awareness of frailty which helps to support flow. Capability of ED /hospital teams to add eFA was increased and extended to Hospital@Home/ community teams. Finally, this has been shared across our NHSL sites.
1649 EVALUATION OF A FRAIL-TRAUMA (“FRAIL-T”) SERVICE IN A SCOTTISH MAJOR TRAUMA CENTRE
Authors: Craig H , Wright E , Capek E
Published: July 2023

Background

Geriatrician assessment is associated with improved clinical outcomes for seriously injured older adults. In 2021, the Queen Elizabeth University Hospital opened a dedicated Major Trauma (MT) ward for adults with significant polytrauma. Four Geriatrician sessions were introduced per week, establishing the ‘Frail-T' service. Our aim was to provide specialist review to frail trauma patients within 72 hours of admission.

Methods

All patients reviewed were prospectively added to a secure database. Patients >65 years on the MT ward were screened for frailty and reviewed if Clinical Frailty Score (CFS) >4. If medical issues arose in patients CFS ≤4, input was provided upon request. Reviews on Critical Care and surgical wards were provided on referral. Qualitative data collected after service implementation assessed staff satisfaction and service improvements. Our database was compared to analysis from 2019 and cross-referenced with the Scottish Trauma Audit Group (STAG) figures to estimate unmet needs.

Results

220 patients were reviewed between September 2021 and August 2022. Median age was 81. 33.2% of patients were frail. 45% received delirium management intervention. Compared to 2019, median time to Geriatrician input improved in polytrauma patients (5 to 3 days), but head and isolated chest injuries (usually on surgical/medical wards) experienced delays (6 and 5 days respectively). 332 additional patients aged >65 on the STAG database were identified; Geriatrician review was recorded in 38% (n=126). Qualitative feedback deemed the service highly accessible (88%, n=15) with themes of improvement: greater service promotion and educational input.

Conclusions

Only a third of patients reviewed by the team were frail, reflecting requirement for medical expertise in trauma care. Cohorting polytrauma in a dedicated ward with proactive screening has improved time to Geriatrician review. Delays remain for isolated head and chest wall injuries. Improvement work will focus on greater identification of patients beyond the MT ward.
1652 USE OF AN AUTOMATED DIGITAL FLAG FOR IDENTIFICATION OF OLDER PEOPLE UNDERGOING EMERGENCY LAPAROTOMY
Authors: Sanda H , Wissenbach I , Davies E , Burberry D , James K
Published: July 2023

Introduction

In the presence of multiple co-morbidities and frailty, older people undergoing emergency laparotomy warrant higher supportive care. It is evident that geriatrician input to perioperative care plays a crucial role to improve patient experience and outcomes. Whilst we recognised the need for a surgical liaison service and increased compliance with NELA we had limited resources to give. We created an automatic email alert to enable us to see NELA patients and make the maximum use of our clinical time.

Method

An automated email alert was created in July 2022 to identify patients undergoing laparotomy based on theatre coding, we then set up filtering by age and frailty. A surgical liaison service was already established but we were able to target NELA patients from September 2022. Retrospective analysis of local data for Morriston Hospital extracted from 2022 National Emergency Laparotomy Audit allowed comparison of compliance to expected standards by the SOPAS (surgical liaison) service before and after intervention.

Results

There were 225 patients who required emergency laparotomy at Morriston hospital in 2022. 50 patients met NELA criteria of which 30% were > 64 with high CFS and 70% over 80. A 3- month period (March-May) prior to the intervention and 3 months following (Sept-Nov). We showed an increased in compliance with NELA standards from under 10% to over 50% with this intervention.

Conclusion

Significant improvement of 5% to 50% compliance with NELA standards was observed after the intervention of email alert; further to this we noted an issue with the alert working through December 2022 where many patients were not seen. This corresponded with a period of increased mortality. Our aim going forward is to upscale this to align with the BGS Position Statement.
1528 IMPROVING DISCUSSION SURROUNDING RESUSCITATION IN OLDER PATIENTS ADMITTED TO HOSPITAL
Authors: Abbott E , Adams D , Ahmad F , Al-Agib S , Atkinson C , Bettridge A , Cuesta G , Pattison T , Reinoso P , Stiles J , Swe Y , Vilches-Moraga A
Published: July 2023

Introduction

One in three hospitalised patients die within 12 months of admission, rising to 45.6% in individuals aged 85 and older. Resuscitation is rarely successful in this patient group. Most older persons are happy to engage in discussions regarding resuscitation and patients’ and relatives’ involvement is recommended by British Geriatrics Society, General Medical Council and Royal College of Physicians. We aimed to increase the number of resuscitation and escalation of care discussions across our Ageing and Complex Medicine department to 90% by November 2022.

Method

Retrospective review of randomly selected electronic case notes for patients discharged in August 2021, November 2021, March 2022 and August 2022, and November 2022, to determine when resuscitation was discussed and, if not discussed, the reasons why. Interventions included:

1. face-to-face presentation of findings with discussion at departmental teaching,

2. distribution of posters on each ward,

3. discussion between each ward team, to review individual wards results.

Results

388 patient cases were reviewed over 5 data collection cycles. At baseline, in August 2021, 49% patients had discussion surrounding resuscitation, increasing to 69% following intervention 1 (November 2021) and 79% following intervention 2 (March 2022). Follow up in August 2022 showed this increase was not sustained, falling to 64%. After intervention 3 (Nov 2022) this rose again to 72%. August 2022 data was evaluated to identify reasons behind no discussion. The main reason was ‘good baseline’ (31.1%) with no documented reason in 48.3% cases.

Conclusion

Percentage of resuscitation discussions has fluctuated over time, improving following targeted intervention but has not yet reached 90%. The main barriers to success identified included junior doctor change-over, fast patient flow, competing ward priorities and patients/relatives lack of understanding. We hope to integrate teaching regarding resuscitation into our departmental induction, to sustain knowledge and understanding within the workforce.
1606 TREATMENT ESCALATION PLANNING: UNDERSTANDING THE SYSTEM TO ENABLE CHANGE
Authors: Stirzaker A G , Rangar D , Ajaz S K , Aston O , Batchford C , Beretta D , Coke M A , Kelly Z , Palin M , Zainal H
Published: July 2023

Introduction

The 2020-21 Chief Medical Officer report described Treatment Escalation Plans (TEPs) as ‘Realistic Medicine in action.’ Our aim is to increase TEP completion on the Medicine of the Elderly (MOE) wards at the Royal Infirmary of Edinburgh to >90% by July 2023.

Method

Since August 2022, we collected weekly data from a single MOE ward. In October, we upscaled to include four MOE and one stroke ward. The notes of five randomly selected patients were reviewed weekly to see whether they have a TEP, and if so, which parts were completed. To further understand behaviours around TEP completion, we collected qualitative data asking doctors what the triggers and barriers were to TEP completion. 40% found the conversations challenging whereas 30% cited time and environment as barriers. We used this data to generate change ideas. For PDSA cycle 1, we developed a teaching session around TEP conversations. This is delivered regularly to all junior doctors and ANPs in the department. For PDSA 2, we allocated a weekly ward ‘TEP champion’ to highlight patients without a TEP and encourage completion.

Results

Median for TEP completion was 75% on the initial ward, 42% over the four MOE wards and 20% for the stroke ward. All patients with a TEP had their resuscitation status documented. One third of patients did not have a TEP at all. Of the two thirds of patients with a TEP, a quarter were incomplete. Sections on goals of care, communication and interventions were completed in around half.

Conclusion

This project is ongoing with future PDSAs planned to address the barriers of time and environment. PDSA 3 will test the introduction of a mobile TEP phone to enable discussions in a quieter environment. The variation in practice in MOE versus stroke is important and requires further understanding of the barriers specific to stroke.
1611 MEMORY LINK WORKER WITHIN GENERAL SURGERY: A PILOT
Authors: Skinner R , Brown K , Jardine N , Ham S , Humphry N
Published: July 2023

Introduction

The General Surgery directorate at Cardiff and Vale University Health Board secured funding for the appointment of a Memory Link Worker (MLW) for a 12-month pilot in the emergency stream. The aim of the MLW is to improve patient experience for those living with dementia/ cognitive impairment, or those who experience delirium whilst in hospital. In addition, the MLW role should increase awareness and completion rates of “Read About Me” (RAM).

Method

The pilot scheme started in February 2022. Eligible patients were identified by ward staff or the Perioperative care of Older People undergoing Surgery (POPS) team and referred in person or via bleep. The MLW reviewed patients, offered activities, contact families / carers and completed the RAM. MLW input continued for the duration of the admission. Objective assessment of the impact of the MLW interventions on patient wellbeing was completed through Dementia Care Mapping (DCM) – an observational tool to improve person-centred care for people living with dementia.

Results

104 patients have been reviewed to date. Average caseload of 6 patients per week. Average time spent with each patient during their admission is 5 hours 51 minutes. Two thirds of patients engage in activities offered by the MLW. DCM demonstrated a positive impact on patient well-being, mood and engagement. Very few patients were able to self-entertain in the absence of the MLW and those that did were using tools supplied by the MLW.

Conclusion

The MLW role has had a positive impact on patient experience as demonstrated by the DCM process. Further analysis of the impact of the role is underway, including feedback questionnaires from staff members and service-users, as well as re-audit of RAM completion rates. We hope this will support a business case to ensure the MLW is a substantive role in general surgery.
1621 FOUNDATION YEAR 1 DOCTORS’ (FY1S) KNOWLEDGE OF FRAILTY AND COMPREHENSIVE GERIATRIC ASSESSMENT: A COHORT SURVEY OF 31 FY1S
Authors: McStay D , Aurangzeb I , Harrison C , Bertfield D
Published: July 2023

Introduction

The British Geriatrics Society and NHS England recommend that patients aged 65 and over should be screened for frailty when presenting to healthcare services to facilitate early comprehensive geriatric assessment (CGA). Recognition of frailty frequently relies on assessment by FY1s. We sought to assess a) how confident FY1s are in recognising and managing frailty, b) their understanding of CGA, and c) how these change during the year.

Methods

Questionnaires (quantitative and qualitative data) were given to FY1s at induction, 6 months, and 12 months. Teaching sessions on frailty and CGA were delivered. We collated feedback on how frailty recognition and CGA knowledge had altered their assessment of older people.

Results

All FY1 Doctors completed the survey at induction. The 6 months and 12 months surveys were emailed to FY1s. The survey response rate was 100% (31/31), 68% (21/31) and 58% (18/31), respectively. At induction, 23% (7/31) reported they were “quite” or “very” confident in assessing for frailty. This increased to 71% at 6 months and 100% at 12 months. Fifty-two per cent (16/31) of FY1 Doctors were aware of a tool to assess for frailty at baseline, increasing to 100% (18/18) at 12 months. Knowledge of CGA improved less, from 48% (15/31) at baseline to 83% (15/18) at 12 months. There was no association between speciality experience and confidence levels. Feedback from FY1 doctors indicated that frailty recognition allowed identification of patients who may benefit from advanced care planning discussions and triggered early therapy input.

Conclusions

Despite BGS and NHS England recommendations, at induction, FY1s lack confidence in frailty recognition and assessment. Through experiential learning and targeted teaching this improved, not limited to those in geriatric medicine. We recommend final year medical students need increased frailty and CGA specific education to improve their confidence when assessing frail older patients.
1646 CAN USE OF SENSOR TECHNOLOGY PREVENT HOSPITALISATIONS IN FRAIL OLDER PEOPLE AT HIGH RISK OF HOSPITAL ADMISSIONS?
Authors: Lowe G M , Arora A , Lockett A
Published: July 2023

Introduction

There has been significant developments, investment and ambition to use modern technology in admission avoidance in hospitals. Sensor technology has been one area of development.

Method

We used My Sense to improve outcomes for a cohort of High Intensity Users (HIU) frail older patients and compared hospitalisation rates before and after employing Sensor technology. HIU patient consent criteria is 3 Admissions with 40 days Length of Stay.

Introduction of MySENSE:

Aim

Fifty randomly selected HIU patients consented to use My Sense from November 2021 to June 2022. HIU monitors usage via a dashboard with the aim to intervene and reduce the likelihood of deterioration caused by inactivity or illness. HIU contacts the key responders, include liaising with family members, GP, other health/care professionals if unusual patterns or no activity is recorded. For example - bed/chair/toilet/kettle/tap sensor not being activated for some time. Indicators for potential UTI’s, constipation, dehydration, reduced mobility and other conditions if not addressed may result in admission.

Results

• Admissions prior to installation 84 post 54; • Length of Stay prior to installation 909 post 724; • Cost saving = £64,750.00; • Cost of equipment £399 with a monthly subscription fees £39.99 per month.

Conclusion

• Useful to detect any changes to normal pattern improving patient safety

• Early identification of deterioration and early deployment of help for earlier intervention

• Raised patient, family and staff satisfaction/reassurance

• Reduced reliance on acute care

• Reduced level of physical social care support / greater independence

• Useful tool but more detailed studies are needed.
1499 REDUCING HYPOGLYCAEMIA ON THE CARE OF THE ELDERLY WARDS: A MULTIDISCIPLINARY TEAM FOCUSED QUALITY IMPROVEMENT PROJECT
Authors: Vourou P , Campbell N , Nethaji C , Lim J
Published: July 2023

Introduction

Older adults with diabetes are at increased risk of hypoglycaemia during inpatient hospital stays. It was noted that a large proportion of diabetic patients on the care of the elderly wards at North Middlesex University Hospital were experiencing hypoglycaemia so a quality improvement project was devised to address this issue and improve patient safety.

Method

Baseline data was collected in October 2021 by monitoring the glucose levels of 21 diabetic inpatients across three care of the elderly wards over a 72-hour period. The project consisted of 3 interventions introduced on one of these wards. The initial intervention was a poster reminding doctors to check the HbA1c results of diabetic patients. The second was the introduction of a bedtime snack for diabetic patients. The final intervention was the inclusion of a hypoglycaemia report in the nursing handover.

Results

In the baseline data collection 3/21 (14.2%) patients had a recorded episode of hypoglycaemia. Following the introduction of the poster, 0/9 (0%) and 1/9 (11%) patients experienced episodes of hypoglycaemia at 2- and 4-weeks post-intervention respectively. Following the introduction of a bedtime snack, 1/5 (20%) patients experienced an episode of hypoglycaemia at 2-weeks post intervention. Following the introduction of the nursing handover report, 1/8 (12.5%) and 0/5 (0%) patients experienced an episode of hypoglycaemia at 4- and 5-weeks post-intervention respectively.

Conclusions

The high rate of hypoglycaemia in elderly diabetic inpatients is likely to be multifactorial and therefore a multidisciplinary approach is essential. The sample size was too small to draw clear conclusions, but the results suggest that a simple nursing intervention could be effective at reducing the frequency of hypoglycaemia. The next steps will be to formally introduce the nursing handover intervention to the other care of the elderly wards and monitor its impact.
1522 THE IMPACT AND INTERVENTIONS OF A FRAILTY PHARMACIST WITHIN EMERGENCY DEPARTMENT FRAILTY TEAM OF AN ACUTE NHS HOSPITAL TRUST
Authors: Organista L , Rai R , Gaddu R
Published: July 2023

Introduction

Older patients admitted to the emergency department (ED) do not have a pharmacist-led medication review within the comprehensive geriatric assessment (CGA), yet the presenting complaint can be attributed to overprescribing and problematic polypharmacy. Taking ten or more medications increases the risk of hospital admission by 300% due to adverse drug reactions (ADRs)1, therefore a medication review can reduce this outcome by optimising current therapy 2. Responsibility of safely transferring this medication information between care settings is a healthcare professional's duty, as the rate of error is 30 - 70%3.

Method

Patients were identified by the ED Frailty Team according to local frailty criteria, including patients > 65 years presenting with delirium, a fall and/or multi-morbidities. Medicines reconciliation was carried out by the frailty pharmacist, and medications optimised to reduce future harm with investigations prompted where needed. Interventions were categorised. A summary plan was written to the General Practitioner (GP) and each patient was followed up after 4 weeks to assess if received and actioned appropriately.

Results

73 medication reviews were conducted for patients (mean age 84.4 years) from June to September 2022, majority presenting with fall (69%). High-risk medication review was most common intervention (90%), followed by counselling (50%). 92% patients required a pharmaceutical intervention (n=208). GP plans were actioned for 65% patients in Primary Care.

Conclusion

ED frailty pharmacist's input reduced inappropriate polypharmacy and optimised medication for this patient cohort, with majority of care plans carried out appropriately following discharge. A future study could examine re-admission rates of patients in comparison to those without a frailty pharmacist's input.

References

1. Payne RA et al. British Journal of Clinical Pharmacology 2014; 77: 1073–82.

2. Department of Health and Social Care, 2021. Available at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1019475/good-for-you-good-for-us-good-for-everybody.pdf. Accessed 19/1/23.

3. Department of Health, 2011/2012. Available at: www.wp.dh.gov.uk/healthandcare/files/ 2011/01/outcomesglance.pdf. Accessed 19/1/23.
1562 LET’S TALK ABOUT DEATH: IMPLEMENTING GUIDANCE ON LEARNING FROM DEATHS AT HOMERTON HOSPITAL
Authors: Teranaka W , Harrod I
Published: July 2023

Introduction

The National Quality Board published the first Guidance on Learning from Deaths in March 2017, which stated the aim of mortality review processes across NHS Trusts and provided a framework in identifying, reporting, investigating and learning from deaths in care. Homerton Healthcare NHS Foundation Trust considered how best to implement the Guidance: record mortality reviews, increase engagement within the Trust and disseminate learning.

Method

Whilst paper-based mortality reviews had already been conducted by some specialties, there was no Trust-wide process to record data and learnings. In 2018, an in-house electronic Mortality Review Tool was built by clinicians and IT team incorporating the use of CESDI (Confidential Enquiry into Stillbirths and Deaths in Infancy), a scoring methodology used to document quality of care and impact on outcome. Ongoing training for the tool is provided to medical staff and is now used by all specialties. A quarterly multidisciplinary mortality newsletter entitled “Let’s Talk About Death” was launched and is now published on the intranet, available for all members of the Trust. Anonymised clinical case examples are used to illustrate learning points and teaching on death and dying.

Results

Percentage of completion of mortality reviews across the Trust increased from 82% to 99% with the implementation of the electronic Tool in comparable quarters (Q1 2018/2019 to Q1 2022/2023). Consultant-led CESDI scores rose from 76% to 98% over the years (2018/2019 to 2021/2022). The newsletter has led to regular collaboration with all teams involved in supporting a patient with life-limiting illness; has encouraged multidisciplinary focus on dying and has provided a leadership opportunity to geriatric medicine trainees who edit the newsletter.

Conclusion

The Trust’s response to the Guidance has resulted in measurable improvement in data recording and engagement with mortality reviews across all specialties and has reinforced the culture of learning from deaths.
1581 POSTURAL HYPOTENSION – A QUALITY IMPROVEMENT PROJECT
Authors: Mahenthiran M , Easosam M , Ahmad S , Li K Y , Kar S
Published: July 2023

Introduction

Postural hypotension (PH) is an identifiable and potentially reversible cause of falls in elderly patients. The National Audit of Inpatient Falls recommends lying and standing blood pressure (LSBP) measurement for patients aged over 65. Our project aims to review current clinical practice and to develop a standardised approach to correctly investigate and manage PH in patients admitted following a fall to the geriatric department.

Method

We performed two cycles of retrospective data collection across three geriatric wards, looking at percentage of patients investigated for PH and the use of correct technique for LSBP measurements as recommended by the Royal College of Physicians (RCP) guidelines. Between cycles, formal and informal educational strategies were implemented and the RCP LSBP measurement guidelines were displayed on doctors’ noticeboards and blood pressure monitoring devices. A PH sticker was designed to ensure correct technique was used and documented.

Results

Following the interventions, the percentage of patients who had LSBP measurements performed improved from 28% to 96% [p<0.00001(X2 test)]. Introduction of the PH stickers improved use of correct technique from 12% to 37.5%. Performance and documentation of medication reviews for patients diagnosed with postural hypotension improved from 0% to 87.5% and lifestyle advice given and documented improved from 0% to 37.5%.

Conclusions

Our study highlighted the need for further training on investigation and management of PH. Our results demonstrate that educational interventions and a standardised sticker to ensure clear documentation can significantly improve diagnosis of PH. The local Falls Prevention Team are keen to promote use of the sticker across the Trust and we have produced patient information leaflets to ensure that all patients receive lifestyle advice.