bluuebunny/crossref_metadata_2025 huggingface dataset:
Ensuring Patient Care Continuity: An Audit of Discharge Letter Completeness in Accordance with National Standards
Authors: Shehzad Babar , Nevin John Paul , Aguiar Filipa
Published: September 2024

Background

Discharge letters serve as a crucial communication tool to convey essential patient's healthcare information from hospital teams to general practitioners and step-down institutions. In 2013, the Health Information and Quality Authority (HIQA) introduced the National Standard for Patient Discharge Summary Information guideline.

Reference

1. Health Information and Quality Authority. (2013). National Standard for Patient Discharge Summary Information. Retrieved from https://www.hiqa.ie/hiqa-news-updates/hiqa-publishes-national-standard-patient-discharge-summary-information.

Methods

This audit reviewed the completeness of discharge letters of patients admitted under the geriatric service of a tertiary hospital, covering the period between 1st September and 31st December 2023. Twenty-five variables were selected from the HIQA standards. The discharge letters were audited for completeness based on the inclusion of these recommended variables. An acceptable completeness rate of 80% for each variable was established.

Results

Of the total 89 discharge letters meeting the inclusion criteria, the average age of patients was 80.75 [SD12.95] years, with males comprising 60%. Seventeen out of 25 selected variables were 100% complete as they were automatically included by the electronic software. All discharge letters also invariably included diagnosis and hospital course information. Over 80% of the discharge letters met the acceptable threshold of including the items: discharge medication and future actions/follow-up. However, documentation of allergic status and inclusion radiological and blood investigations were only found in 27% and 49% of the letters, respectively.

Conclusion

The audited discharge letters had acceptable rates of completeness regarding inclusion of important items, while documentation of allergic status and inclusion of blood and radiological investigations fell below the acceptable standard. Of note, those that were automatized achieved 100% compliance. Regular auditing of discharge letters should become standard practice to improve completeness and ensure patient care continuity and safety. Consideration should be given to automatization of inclusion of reports of investigations.
Early Mobilisation Post-Thrombolysis is Safe and Improves Outcomes in Mild-Moderate Acute-Stroke Patients
Authors: Harte Mary , Newell Evelyn , Galvin Trish , Walsh Thomas , Scanlon Maeve
Published: September 2024

Background

Thrombolysis (tPA) is the delivery of a clot-lysing agent used in acute ischemic stroke, typically followed by ≥24-hour bed rest. This study aimed to compare the safety and effectiveness of early mobilisation (≤24 hours post-tPA) versus ≥24-hour bed rest in patients with mild-moderate stroke.

Methods

A literature review was conducted leading to the development of an early mobilisation protocol post-tPA. Retrospective (January-July 2023: pre-early mobilisation protocol) and prospective (July 2023-April 2024: post-early mobilisation protocol) data were analysed. Baseline demographics and outcomes were compared between the two groups. Primary outcome was physical function (Modified Rankin Scale (mRS) at hospital discharge. Secondary outcomes included adverse effects, length of stay (LOS) and discharge destination.

Results

11 patients met the criteria for early mobilisation in both groups. There were no significant differences in age, the National Institutes of Health Stroke Scale (NIHSS) pre-tPA and mRS at baseline between the two groups (p>0.05). 8 patients in the early mobilisation protocol were male (72.73%), the median (IQR) age was 61 (54-78) years, and NIHSS was 6 (3-8) pre-tPA and 1 (0-2) post-tPA. Patients had a median (IQR) mRS score of 0 (0-0) pre-stroke and time to early mobilisation was 12 (12-17) hours. Patients in the early mobilisation group had significantly lower mRS on discharge (p=0.007), shorter LOS (Median (IQR) 5 (4-7) days, P=0.13) and higher rates of discharge directly home compared to those mobilised post ≥24-hour bed rest. No adverse effects of early mobilisation occurred.

Conclusion

Compared with 24-hour bed rest, early mobilisation for mild-moderate stroke patients was safe and associated with significantly better physical function.
The POISE Study: POcus for Identification of Sarcopenia in Emergency departments
Authors: Collins Bridget , Turcuman Eduard , Umana Etimbuk , Magner Siobhan , Carey Sive , Pender Ciara , Byrne Colm , McDermott Cian , Breslin Deirdre
Published: September 2024

Background

Sarcopenia is a progressive loss of muscle mass and strength, primarily affecting older adults, with a prevalence of up to 20% in >65-year-olds. It is associated with poor outcomes such as fractures, falls, loss of independence and mortality. Recent studies into the use of ultrasonography for sarcopenia diagnosis have yielded promising results, with good validity to estimate muscle mass when compared to DXA, CT or MRI. While point-of-care ultrasound (POCUS) is a commonly used technique in Emergency Medicine, its applicability to sarcopenia diagnosis in an ED setting has not been investigated.

Methods

This was a prospective, cross-sectional, observational pilot study. Patients >65 years were recruited sequentially from the ED triage list. Each subject had a POCUS scan of their thighs, to visualise and measure the thickness of the femoral quadriceps. Subjects’ handgrip was then measured using a digital grip strength dynamometer. Subjects’ gait speed was measured in metres per second using a standard 6 metre walk test. Data was then analysed to examine any correlation between muscle thickness on POCUS and functional measures of sarcopenia.

Results

60 patients were recruited into this pilot study. Of these, 50% had evidence of sarcopenia on functional assessment. There was a statistically significant correlation between muscle thickness on POCUS and performance on functional assessment.

Conclusion

This pilot study demonstrates a possible new application for POCUS in the ED. This could guide therapy for falls prevention and may prevent further morbidity in this vulnerable population. Further research is needed to confirm the results of this pilot study within a wider population. Additional research examining the correlation between POCUS findings, Clinical Frailty Scale, and BMI would also be of benefit.
An Exploration Of Delirium Awareness Amongst Clinical Staff Working On The Acute Floor Of A Level Three Hospital
Authors: Tormey Sarah , Smyth Jennifer , Flynn Aoife , Owens Mary , O'Neill Aisling , Heduvan Karen
Published: September 2024

Background

Delirium is an acute change in cognitive function that has an organic cause and is likely to be reversible or preventable (HSE Delirium Algorithm, 2021). The Frailty Intervention Team (FIT) based in the Emergency Department (ED) & Acute Medical Assessment Unit (AMAU) comprises of Physiotherapy, Occupational Therapy and Dietetics and is supported by an Older Persons Advanced Nurse Practitioner. The 4AT delirium screen is routinely completed by FIT as part of Comprehensive Geriatric Assessment. FIT observed limited use of delirium screening in ED/AMAU therefore we proposed to explore delirium awareness amongst all clinical staff on the acute floor.

Methods

All clinical staff in ED/AMAU were invited to complete an anonymised paper questionnaire to explore their awareness of delirium. Basic statistical analysis of data was completed using Excel.

Results

Over one week twenty-four questionnaires were completed by medical, nursing, allied health and health care assistants. Six questions explored delirium awareness and a seventh question explored the willingness to engage in delirium information sessions if made available to staff locally. On assessment of delirium awareness an average score of 79.3% (range 16.7%-100%) was achieved. Participants scored strongly on potential causes of and screening for delirium. Questions relating to delirium symptoms and potential outcomes of unrecognised delirium had the least correct response rates. 100% of respondents expressed interest in attending delirium information sessions if made accessible to them within ED/AMAU.

Conclusion

This study identified overall satisfactory delirium awareness amongst clinical staff on the acute floor and all participants expressed interest in expanding their knowledge in this area. Compliance with use of delirium screening tools in clinical practice was not assessed and we also acknowledge the limited number of participants. Future plans include audit of the use of delirium screening tools, delivery of delirium information sessions and provision of accessible delirium resources in ED/AMAU.
Potentially Inappropriate Medications and De-prescribing: An Audit of STOPP/START on an Inpatient Rehabilitation Ward
Authors: Kemple Orla , Karpinski Sylvia , Fallon Aoife
Published: September 2024

Background

Polypharmacy is well recognized in older adults with many adverse outcomes. Practical tools, such as the ‘STOPP/START’ criteria, aid clinicians in de-prescribing to tackle medication related morbidity. Current research suggests these tools are insufficiently implemented in clinical practice (1). Many older adults require rehabilitation after acute hospital admissions which can provide an ideal setting for medication review and de-prescribing.

Methods

A retrospective audit was carried out of 35 older adults in a gerontological inpatient rehabilitation facility between 8th February and 8th April 2024. Demographic and clinical data was collected using electronic and handwritten patient records. Each patients’ medication prescription was reviewed from date of admission to rehabilitation facility. Number of medications prescribed was recorded. Using the ‘STOPP/START’ criteria, potentially inappropriate medications (PIMs were identified, and de- prescribing was noted for the PIM where taken.

Results

35 patients were included in the study. No patient was excluded. Mean age was 86.14 years and mean number of prescribed medications per patient was 11. The most common presenting complaint was a fall in 57.14% of patients, in which 95% had acute fracture. Other presenting complaints for acute admission included delirium and infection. Mean clinical frailty score was 5.71. 38 PIMswere identified, totalling 10% of all medication prescriptions. Of these, 12 de-prescribing opportunities were taken, one of which was a dose reduction. The most common PIMswere prescribing of PPI at full therapeutic dose (n=12), inappropriate opioid prescribing (n=4) and hypnotics (n=7) in high-risk groups.

Conclusion

Polypharmacy and PIMsare common in older adults and are related to adverse outcomes, especially in frail adults at risk of falls, fracture, and delirium. The rehabilitation setting is an ideal location for use of de-prescribing tools however their implementation varies. This may be improved by education and structured medication review in collaboration with trained pharmacists.
Safer Care for Older People in the Emergency Department
Authors: Brady Antoinette , McMackin Eamonn , Subramaniam Dineshkumar , Quirke Caithriona , Donnelly Teresa , McGlynn Joanna , Hughes Helen , Kennedy Lisa , Morgan Victoria
Published: September 2024

Background

The number of over 75-year-old patients (O75YOs) presenting to our Emergency Department (ED) has increased by 35% since 2020 and continues to rise. It is well documented that older people present more frequently to EDs with a higher level of illness severity, a higher rate of admission or re-attendance and are at a greater risk of adverse outcomes such as falls, delirium, prolonged ED and/or hospital stay and ultimately mortality (Tan et al. 2012). We developed a safety huddle to identify and reduce risks to older people in our ED with a view to improving their outcomes.

Methods

Our 10-minute huddle took place each day at 3pm (peak occupation time of O75YOs). An ED physician, nurse, AHP and Geriatrician/Registrar were required to attend. The huddle script was developed based on feedback from clinicians and a literature review on risks associated with an ED presentation in older adults. The script focused on recording resourcing issues critical to patient care. The primary risk factors recorded included falls risk, delirium, administration of time critical medications and PET times. Following the huddle, HCPs involved in the patient’s care were updated by the relevant member of the MDT in attendance to ensure agreed interventions were completed/in place.

Results

We observed a decrease in the number of falls from 2 to 0. Delirium screening improved from 0% to 26%. Identification and administration of time critical medications improved from 0% to 78%. PET times increased slightly (2%), however admission rates decreased indicating value added to the patients’ journey.

Conclusion

Whilst we acknowledge there is still room for improvement, these results will clearly have a positive impact on patient outcomes.
Engaging with First Line Nutrition Information - Insights from Health Care Professionals and Older Persons
Authors: King Lorna , Devaney Catherine , Sayers Karen , Donnellan Christina
Published: September 2024

Background

Health care professionals (HCPs) working with older persons are often asked nutrition related questions. This study explored how first line nutrition information such as general leaflets are accessed and used by HCPs and older persons. Is there a role for video-based nutrition education?

Methods

HCPs working with older persons completed an online survey. An older person’s reference group participated in a virtual focus group. Participants were asked about knowledge seeking, accessing and providing nutrition information, and engaging with videos on nutrition topics. Results were analysed using descriptive statistics and thematic analysis.

Results

Ninety five HCPs completed the survey (44% Nursing, 27% Physiotherapy, 14% Occupational Therapy, 6% Speech & Language Therapy and 9% other (doctors, social worker, pharmacist and care needs facilitator).Eighty-eight (90%) HCPs reported being asked nutrition related questions, topics included poor appetite (n=77, 83%), weight loss (n=68, 75%) and constipation (n=66, 72%).Twenty HCPs (21%) reported confidence answering questions, while 28 (29%) reported low confidence. Forty-three (44%) had little or no awareness of available first line information and 37 (39%) rarely or never provided information. Eighty-two (86%) HCPs agreed that nutrition education videos would be used if available. Three themes emerged from the HCPs survey: (i) importance of nutrition for HCPs (ii) barriers to use of first line information and (iii) support systems. Fourteen persons (64% women, 36% men) attended the focus group. Two themes were identified: (i) access to health information and (ii) barriers to access. Discussions included difficulty in proactively seeking information, joined up sharing and that education videos would be beneficial, but the distribution needed consideration.

Conclusion

Timely access to information is empowering for the older person. HCPs were identified as a resource for seeking nutrition advice. The communication of and access to nutrition information merits consideration. Following these findings, nutrition videos are currently being developed.
Audit of Lithium Monitoring in a Mental Health for Older Persons (Dublin North City Central) Service
Authors: Murphy Fiona
Published: September 2024

Background

Lithium is a psychotropic medication used for the treatment of bipolar affective disorder and augmentation for treatment resistant depression. Lithium monitoring is essential due to the narrow therapeutic range of serum lithium and the potential for toxicity. Other medications with similar risk profiles, such as warfarin, have established monitoring programmes. Older adults receiving lithium therapy are at an increased risk of adverse events, given the prevalence of medical co-morbidities and changing pharmacokinetics. The authors of this audit identified the lack of formalized lithium monitoring programme in the Mental Health Service for Older Persons (MHSOP). The aim of this audit to compare monitoring practices in the MHSOP against the current gold standard Irish Medication Safety Network (IMSN) for Prescribing and Monitoring of Lithium Therapy.

Methods

A survey of all community medical charts identifying patients attending the service receiving lithium therapy was completed. Data collected pertained to diagnosis, treating consultant, lithium dose, if the patient received educational material, compliance with ECG and blood monitoring.

Results

The MHSOP active case load was 682 patients, 14 patients were prescribed lithium therapy. Cycle 1 of the audit demonstrated poor compliance of lithium monitoring against the gold standard. A lithium pack was inserted in patient files to prompt all clinicians to follow the recommended standardized monitoring of lithium therapy as per the IMSN guidelines. In cycle 2 of the audit there was an improvement in recording blood monitoring across the patient group.

Conclusion

The audit demonstrated improvement in compliance with international guidelines following the intervention. It was recommended that a formalized Lithium Clinic was a needed resource for the MHSOP. The lithium monitoring pack will continue to be added to clinical files, included in Non-Hospital Consultant (NCHD) induction and multi - disciplinary teaching sessions. It is proposed that the audit be repeated in one year to longitudinally assess compliance.
Evaluation of an Occupational Therapy led Cognitive Stimulation Therapy Programme in an Integrated Care Programme for Older Persons
Authors: Campbell Judith , Cosgrove Julie , Fitzmaurice Cliodhna , McDonnell Ciara , Rogan Mary , McClean Fiona , Geoghegan James , Canavan Michelle , Costello Maria
Published: September 2024

Background

Cognitive Stimulation Therapy (CST) is a non-pharmacological, evidence-based approach specifically designed to support people with dementia to maintain their cognitive functions e.g. reminiscence, higher executive skills, sensory integration, orientation, memory strategies and day-to-day activities.

Methods

Participants referred to a community specialist ICPOP team were identified for CST following Comprehensive Geriatric Assessment (CGA), where cognitive impairment or dementia was identified. Inclusion criteria: Rockwood Clinical Frailty Scale ≤5, Barthel Index of Activities of Daily Living ≥11, Lawton Brody Instrumental Activities of Daily Living Scale (IADL) ≥4, Montreal Cognitive Assessment (MoCA) ≥10, and ability to consent to participate. Addenbrooks Cognitive Examination (ACE-III) scores were obtained pre and post CST, alongside post CST feedback questionnaires.

Results

5 CST programmes of seven weeks duration were conducted over a ten-month period. 31 (male=16, female=15) participants completed the programme. 3 participants dropped out due to lack of transport/interest. The average ACE-III score pre-CST was 68.3 +/- 14.31; post-CST was 76.1 +/- 11.4. 28 participants completed feedback questionnaires. Positive feedback included “Got a great sense of achievement with each session, and eagerly looked forward to the coming weeks”, “Each session topped the previous session” “Gave me a reason to get out, a routine to my week”. 45 % commented that they felt safe sharing difficulties/problems with the group. 71% reflected that CST provided an opportunity to meet others in a similar situation. 100% would recommend CST to others.

Conclusion

Experience of CST was overwhelmingly positive demonstrating benefit not only from a cognitive perspective but from informal peer support and connections made in group settings. Participants commented on lack of follow-on programmes, identifying the need to develop maintenance CST programmes led by trained community stakeholders which would sustain these benefits long-term as well as increasing awareness and knowledge of dementia within communities.
Trauma Presentations To The ED, Are We Improving With Frailty Initiatives?
Authors: Kennedy Lisa , Barnes Annemarie , Hughes Helen , Brady Antoinette , Morgan Victoria , Kelly Patricia , Kazi Durriya , Donnelly Teresa , Eager Robert
Published: September 2024

Background

An emergency department serving as a regional Trauma Centre for the Midlands, now has a Rapid Access Frailty Team (RAFT) which provides timely assessments of all Frail patients over 75. The department has an approximate trauma attendance of 111 (2023 figures) annually within this age cohort. In line with our NOCA guidelines we performed a retrospective review of our trauma presentations since the introduction of the RAFT initiative, looking at the patient’s presentations and how interventions can improve our Trauma management.

Methods

This was a retrospective review of FRAIL positive patients in from January/February 2023 and January/February 2024 based on NOCA 2021 subsets of trauma data. Data was collected using examination of IPIMS and ED notes obtained for review. We compared both years to see we could see if RAFTT interventions improved our trauma triage and care.

Results

The predominant mechanism of injury remains to be a fall (85% in 2023 and 74% in 2024), and the majority of traumas being in the home setting (70% in 2023 and 78% in 2024). By the early involvement of a nurse specialist, physio/OT and doctor, time to be seen has reduced by 23% since the introduction of the team, time to imaging has improved by 51% and time to bed if admitted has improved by 19%. Pre alerts remain low, similar to national data findings (10% in 2023, but up to 15% in 2024).

Conclusion

Data points to the team’s provision of timely, patient-focused assessments and interventions for the older person are improving outcomes. The unique assessment skills that the team deliver aids rapid assessment, supports timely decision-making and referral as appropriate; improving the patient’s journey by either facilitating early discharge or providing early goal-setting therapy interventions at the start of the hospital journey.
Dietetic Needs in a Memory Assessment & Support Service (MASS) – A Retrospective Analysis
Authors: McGuinness Aideen
Published: September 2024

Background

Nutrition issues can occur in all stages of cognitive impairment, but individual needs may not always be promptly identified.

Aim

To evaluate dietetic needs of this cohort.

Methods

Retrospective service evaluation of first 50 referrals to a MASS Senior Dietitian, including comparison of nutrition-screening tools validated for older persons: Mini Nutritional Assessment-Short Form (MNA-SF)1 and Malnutrition Universal Screening Tool (MUST)2.

Results

The first 50 dietetics referrals (total 126 consults) representing 16% of MASS clients in this period.

Nutrition screening:

MNA-SF MUST

≤ 7 18% malnourished/high risk ≥ 2 34%

8-11 72% at risk of malnutrition 1 32%

12-14 10% not nutritionally at risk 0 34%

So MNA-SF identified 90% as malnourished or at risk, while this was 66% with MUST.

Individually tailored advice included:

Resolution of key issue and discharged (17), 2 clients deceased.

Remainder (31) ongoing dietetic follow-up.

Conclusion

For those with memory impairment early and regular nutrition assessment is important, and the MNA-SF tool is appropriate. Expert Dietetic advice is necessary at all stages of memory impairment.
ICOP Dietetics – The First Year
Authors: McGuinness Aideen
Published: September 2024

Background

All clients referred to Integrated Care for Older Persons (ICOP) for falls, frailty or functional decline have a Comprehensive Geriatric Assessment (CGA) including nutrition screening, which may trigger dietetic referral.

Methods

Retrospective analysis of initial year of a Senior Dietitian (0.5WTE).

Results

172 referrals - representing 28% of ICOP clients. 14 did not engage. Age 56-95, Clinical Frailty Scale 3-8 (median 5). 304 consults: 40% one consultation, 40% 1-2 reviews, 20% 3-6 reviews.

Nutrition screening

Mini Nutritional Assessment-Short Form (MNA-SF)1 score ≤ 7 16% malnourished, 8-11 55% at risk of malnutrition, 12-14 29% not nutritionally at risk. So, 71% categorised as either malnourished or nutritionally at risk. While not assessed in all cases, probable sarcopenia2 was documented in 42% clients using grip strength. Individually tailored advice included (n=158):

141 discharged after individualised dietetic advice. Seven clients deceased. Remainder (nine) ongoing.

Conclusion

Those attending ICOP have a high prevalence of nutrition concerns, nutrition screening is important, and expert dietetic advice is essential to ensure guidance is evidence-based and resources are appropriate.
Angiotensin Receptor Blockers, But Not Angiotensin Converting Enzyme Inhibitors, Improve Bone Mineral Density: Results From The TUDA study
Authors: Fitzpatrick Donal , Laird Eamon , Lannon Rosaleen , Ward Mary , Hoey Leanne , Hughes Catherine F , Strain JJ , McNulty Helene , Cunningham Conal , Molly Anne , McCarroll Kevin
Published: September 2024

Background

Both hypertension and osteoporosis are common in older adults and frequently co-exist. The renin angiotensin system has been implicated in osteoclast activation and bone loss. Several studies have previously examined the relationship between various inhibitors of RAS and bone mineral density (BMD). In this study we examined the relationship between angiotensin receptor blockers (ARBs) and angiotensin converting enzyme ACE inhibitors and BMD.

Methods

Study participants were from a cross-sectional study of adults aged >60 years; Trinity Ulster University Department of Agriculture (TUDA) study. We excluded participants on treatments for osteoporosis. In users and non-users of ARBs and ACE inhibitors, we compared least squares means BMD measured by densitometry at the neck of femur, hip, and lumbar spine adjusted for age, sex, body mass index, timed up and go, vitamin D, parathyroid hormone, eGFR, diabetes mellitus, smoking, alcohol consumption, dairy intake, glucocorticoid exposure, thiazide, and loop diuretic use.

Results

There were 2218 participants (mean age 70.1±6.5 years, 58.3% female, 23.4% (n=519) on ARBs and 30.9% (n=686) on ACE inhibitors). In both univariate and multivariate analysis, ARB users had higher BMD than non-users were associated with higher BMD at the neck of femur (0.860 g/cm² vs. 0.846 g/cm², p=0.016); at the total hip, (0.938 g/cm² vs. 0.919 g/cm², p=0.004); at the lumbar spine, BMD was 1.106 g/cm² vs. 1.074 g/cm² p< 0.001). No significant relationship between ACE inhibitors and BMD at any site was observed after multivariate adjustment.

Conclusion

ARBs were associated with improved BMD while ACE inhibitors were not. Similar results have been found in other studies but the mechanisms but there is substantial uncertainty regarding the mechanisms underlying these relationships. These findings could be important in the choice of antihypertensive agent in older patients at risk of fracture and further research is warranted.
Goals of Care Discussions Among Patients Who Suffer Cardiac Arrest
Authors: Oyuga Michael , McCormick John P , Power Hayley , Ryan Seán , Regan Anne , Trueick Robert , Nally Fionn , Al-Harthi Faisal , O'Boyle Patrick
Published: September 2024

Background

Outcomes following in-hospital cardiac arrest remain poor despite advances in resuscitation techniques. Establishing “goals of care” is crucial to optimizing patient care and avoiding burdensome interventions in those who are unlikely to benefit from resuscitation. Doctors often avoid discussions regarding ‘goals of care’ with patients in whom cardiac arrest is not deemed likely at the time of admission.

Methods

All cardiac arrest team activations for non-pregnant, adult inpatients on medical and surgical wards at our institution from December 2022 – June 2023 were prospectively analysed. Qualitative analysis of inpatient charts was performed to assess; incidence of cardiac arrest, demographic and clinical data, and the degree to which discussions regarding escalation of care had taken place.

Results

66 cardiac arrest team activations were screened, of which 23 calls were included for analysis. The estimated incidence of cardiac arrest was 1.11-1.67 events per 1,000 patient discharges. 18 patients (78.2%) were under the care of general medicine or geriatric teams at the time of arrest call. 12 (52%) patients were older than 70 and 4 (17%) were older than 80. Falls were the most common reason for admission (22.7%) among patients for whom the cardiac arrest team was activated. 2 patients (12.5%) with confirmed cardiac arrest survived to hospital discharge. Discussions regarding goals of care were documented for 8/23 patients (34.7%).

Conclusion

Cardiac arrests were uncommon in our institution. Discussions regarding goals of care were documented in only a third of cases, possibly because many patients presented with issues not typically associated with a risk of subsequent arrest. Given the low survival rates to discharge, routine discussion of goals of care should be considered at the point of admission in all patients who are unlikely to benefit from resuscitation, regardless of the presenting complaint.
Integrated Care in Action: A Case Study of Collaborative Multidisciplinary Approach for Older Adults in Ireland
Authors: Dooley Marie
Published: September 2024

Background

In Ireland, the healthcare landscape is evolving with frameworks which emphasize community-based care, such as Enhanced Community Care and the National Integrated Care Programme for Older Persons. Our Integrated Care Team for Older Persons (ICPOP) service exemplifies this shift by providing intensive, immediate multidisciplinary care to frail adults, aiming to maintain their independence in their homes and communities.

Methods

In the case study we describe service users journey with ICPOP. The case study illustrates the transition from fragmented care to a collaborative, patient-centred approach. ICPOP employs a structured process involving comprehensive assessment, goal setting, weekly multidisciplinary team meetings, stakeholder liaison, and detailed discharge reports. This approach focuses on early supported discharge and close coordination with local MDT teams, fostering effective communication and shared decision-making.

Results

This case study demonstrates the effectiveness of ICPOP's multidisciplinary model. Key factors contributing to this success include physical co-location, shared goals and vision, mutual trust, and established relationships among professionals. Furthermore, the integration of Allied Health Professionals (AHPs) within community teams enriches the care continuum and enhances outcomes for older adults.

Conclusion

To further enhance integrated care delivery, digital solutions are crucial. Implementing shared electronic health records and facilitating access to medical findings can streamline communication and improve care coordination. Additionally, prioritizing written discharge summaries for clients can ensure continuity of care and empower patients and their families in the post-discharge phase. This patient journey underscores the importance of collaborative, patient-centred care models in achieving the objectives of Sláintecare leading to better outcomes for older adults in Ireland.
Predictors Of Handgrip Strength And Its Relationship To Physical Performance In Older Irish Adults
Authors: Fitzpatrick Donal , Laird Eamon , Lannon Rosaleen , Cunningham Conal , Ward Mary , Hoey Leanne , Hughes Catherine F , Strain JJ , McNulty Helene , Molloy Anne , McCarroll Kevin
Published: September 2024

Background

Handgrip strength declines with age and predicts poor physical performance and increased risk of falls and mortality. However, the strength of the relationship between handgrip strength and other physical measures is less well studied. We aimed to explore the predictors of handgrip strength in older Irish adults and its relationship to the Timed and Up and Go (TUG).

Methods

Study participants were from a longitudinal cohort of Irish adults aged >60 years; Trinity Ulster University Department of Agriculture (TUDA) study. Participants on current or long-term steroids, a history of stroke and with MMSE <24 were excluded. Handgrip strength was assessed with a dynamometer and defined as <27 kg for males and <16 kg for females. Abnormal performance in the TUG was defined as >12 seconds. Predictors of impaired handgrip were explored in multivariate logistic regression.

Results

There were 748 participants (68.9% female, mean age 70.2 years), of whom 33.4% had abnormal handgrip strength, which was more common in female’s vs males (39.4 vs 20.2%, p<0.001). Both abnormal handgrip strength and TUG was present in 13.6%. Normal handgrip strength had a negative predictive value of 76.0% for ruling out poor TUG, while abnormal handgrip had a positive predictive value of 62% for poor TUG. Predictors of impaired handgrip strength were older age (P<0.0001), female sex (p<0.0001), lower protein intake (P=0.024) and higher waist hip ratio (p=0.014).

Conclusion

Handgrip strength had a modest correlation with TUG A significant proportion had abnormal TUG but normal handgrip. Changes in lower limb muscle strength (affecting TUG) precede muscle loss in the upper limb. Higher protein intake predicted greater grip strength and supports the recommendation to maintain adequate intakes to prevent sarcopenia. Greater waist hip ratio is associated with reduced lean muscle mass which may explain the negative relationship we identified with handgrip strength.
Retrospective Review of Falls in Medical Inpatients Following Introduction of a Falls Proforma at Wexford General Hospital
Authors: Geraghty Timothy , Boyle Niamh , McNamee Mary , Kelly James , Lucey Kieran , Harkin Eithne
Published: September 2024

Background

Inpatient falls are the largest category of preventable inpatient adverse events in hospitals coming at both great financial and safety cost to a healthcare system. Approximately 30% of inpatient falls result in injury, 4-6% resulting in serious injury with older patients have the highest risk of falling and injury. The aim of this retrospective audit cycle was to improve standards of falls assessments performed by junior doctors.

Methods

We initially conducted a retrospective review of 7 medical inpatient falls in July 2023. Standards were compared against NICE Guidelines on Assessment and Prevention of Falls in older people 2013 and NICE guidelines on Assessment and early management of head injury 2023. 15 key elements were analysed: doctor identifier, date and time, history of fall, confusion, pain, loss of consciousness, amnesia, seizure, vomiting, medication review, hip fracture, wrist fracture, skull fracture, Glasgow Coma Scale and neurological deficit. One point was given for each of the 15 key elements noted in the falls review. Following introduction of a falls proforma, we re-audited 18 falls in February 2024 to analyse differences in scores.

Results

Prior to proforma introduction, 7 falls reviewed had an average score of 3 points. 4 falls were reviewed by SHOs, 1 each by an SpR and Intern and 1 NCHD review was unidentifiable. Mean age was 72. Following proforma introduction, 18 falls in 13 patients were analysed. 2 patients did not have a falls review, 15 were reviewed by SHOs, 1 by an Intern. Average age was 81. Proforma was used in 7 cases with an average score of 12.7, and no proforma was used in 11 cases with an average score of 5.

Conclusion

These findings demonstrate improved quality of falls reviews using proformas in line with guidelines compared to those without. More education is needed to incorporate proformas into standard practice.
Playing Ping- Pong: Keeping Frail Older Adults Out Of Hospital
Authors: Staunton Ruth , Davis Aisling , O'Kane Aoibhean , Smith Finola , Doyle Cliona , Hilery Patrick , Namara Rosa Mc , Boyle Nicola
Published: September 2024

Background

EDITH (Emergency Department in the home) is a rapid response team consisting of a doctor/Advanced Nurse Practitioner and Occupational Therapist who assess patients in their home to avoid an ED attendance. The Integrated Care Team for Older People (ICPOP) is a community-based specialist multidisciplinary team that provides assessment and intervention for frail older adults in order to maintain them living at home. The teams have developed a close working relationship and utilise each other’s services to provide right time, right place patient care with the ultimate shared goal of keeping older adults living well at home.

Methods

A high frequency service user was identified, and a retrospective chart review was completed between the two teams. Outcome measures such a CFS, 4AT, medical status, social supports and environment set up were noted. Patient journey was conceptualised and handover of medical responsibility from team to team was explored along with identifying other factors that maintain older adults living well in their homes.

Results

Over a 12-month period, patient X case was “ping ponged” between the two services. The patient attended ED with EDITH review in the home facilitating a direct discharge home. The ICPOP team provided ongoing interdisciplinary and specialised intervention. ICPOP also identified changes to medical status that warranted timely EDITH review and thus negated the need for ED attendance. Patient X avoided a hospital admission during that period due to co working and open communication between both teams.

Conclusion

Rapid access, timely communication and team work between the EDITH/ICPOP yielded a positive result for patient X and allowed them to remain at home, despite a high level of frailty and low threshold for hospital admission. It appears that having services working with a collaborative approach affords better outcomes for this vulnerable population and reduces pressure on hospital resources.
Appropriate Prescribing of Antipsychotic Medication Amongst Long-Term Care Facility Residents Admitted to Hospital
Authors: O'Mahoney Niamh , Power Leslee , Mello Sarah
Published: September 2024

Background

In Ireland, it is estimated that up to 45% of long-term care facility residents (LTCR) living with dementia are prescribed antipsychotic medication1. Although antipsychotics have moderate benefit in treating neuropsychiatric symptoms, their use must be carefully weighed against an adverse side effect profile. This study aims to describe the prevalence of antipsychotic usage in LTCR admitted to hospital, and to determine the appropriateness of the prescription as outlined by the National Clinical Guideline 21. This study describes the efficacy of a new Nursing Home Liaison (NHL) service (consisting of two advanced practice nurses) in reducing inappropriate prescribing.

Methods

Hospital admissions were screened daily to identify LTCR. Medical chart and drug kardex review was performed to collect demographic data, dementia diagnosis, and antipsychotic prescription. Anticholinergic burden was calculated using the ACB score. If the indication for antipsychotic was not clear post review, the NHL service obtained collateral history to determine reason for prescription, making recommendations to wean and stop the medication where appropriate.

Results

Data was prospectively collected on 50 consecutive LTCR, 28 (57%) were male and the average age was 81years. 26 (51%) of patients had a diagnosis of dementia. A total of 11 (22%) patients were prescribed antipsychotics; of these, seven (64%) had dementia and the rest had psychiatric diagnoses. The mean anticholinergic burden was 2.4 (range 0-7). Five (45%) of the antipsychotic prescriptions were not justified as per Guideline 21 or were no longer needed. These were amended as per the advice of the NHL service.

Conclusion

This study highlights rates of inappropriate prescribing of antipsychotics among LTCR, resulting in high anticholinergic burden and the associated risks. Medication review and advice from a specialist NHL service, was effective in reducing inappropriate prescriptions. Further education and dissemination of Guideline 21 is prudent to ensure proper prescribing and de-prescribing practices.
Silver Fast Track – Prioritising People Over 75 in the Emergency Department (ED)
Authors: Sankey Ciara , Linehan David , Latoza Wendelene , Carville Michelle , O’Neill Siobhan , Hart Dominic , Marks Marian
Published: September 2024

Background

The National Emergency Medicine Programme prioritised the care of older adults in a three-year Unscheduled Care Improvement Programme, coinciding with the “Integrated NCAGL Acute Operations and Older Persons body of work on Older Adults with Frailty in Acute hospitals”. In May 2023 a three-month pilot in the ED commenced to reduce the time for people over the age of 75 awaiting assessment by a doctor. Using the Manchester Triage system, a separate filing box on triage (Category 3+) was created to identify all people aged over 75 years who would then be prioritised to be seen within 4 hours of arrival. In addition, if a person aged over 75 years was waiting over 4 hours to be seen they would be re-triaged and seen within 15 minutes (Category 2).

Methods

A Prospective analysis of waiting times for people aged over 75 years, assessing: (1) time to be assessed by the Older Persons Assessment and Liaison (OPAL) Team; (2) time to see the ED doctor and (3) time to discharge.

Results

Four months prior to commencement, the median time from arrival to be seen by OPAL was 10 hours 58 mins. Following commencement, for the remainder of 2023, the median time from arrival to seen by OPAL was 6 hours 36 mins. The time to see the doctor reduced by 49 mins and time to discharge reduced by 1 hour 19 minutes.

Conclusion

The category 3+ for patients aged over 75 years is now an established feature in the ED. It has enabled the OPAL team to undertake earlier assessment of the patients journey alongside the medical team ensuring a more collaborative discharge pathway. In the future, we hope to further reduce the time to be assessed by OPAL through the introduction of clinical frailty scoring at ED triage & expanding the team.
A Profile of Patients Undergoing Comprehensive Geriatric Assessment Though Irish; An Bhfuil Gaeilge Níos Fearr?
Authors: Neachtain Máire Ní , Fitzmaurice Cliodhna , Abed Aishling , Brehony Alma , McCleane Fiona , Canavan Michelle , Costello Maria
Published: September 2024

Background

The CSO 2022 reported that there were 1,873,997 Irish speakers in Ireland >3yrs of age. Of those, 71,968 speak the language daily. The highest proportion of those who speak Irish in Ireland live in the West of the country. Within our catchment area, we are able to provide an ANP led comprehensive geriatric assessment (CGA) in the Irish language.

Methods

The aim of this study was to characterise participants referred to an integrated care for older persons (ICPOP) service who had CGAs conducted in Irish from the period of September 2023 to April 2024 and to determine if the patients felt better represented if their CGA was conducted through Irish. Two questions were asked, 1. Do you prefer to have healthcare interaction through Irish? 2. Do you feel better represented by having had your CGA conducted in Irish?

Results

Over a six-month period 34 patients referred to ICPOP underwent CGA or review through the Irish language. 35.2% (n=12) had their CGA conducted at home. 23.5% (n=8) of those were referred for frailty, 23.5% falls (n=8) and 53% (n=18) for assessment of cognition. Of this cohort 32.3% (n=11) were female, had a median age of 81.5 years and a median clinical frailty score of 5 (range 3-7). The average age of education completion was 14.8yrs. 3% (n=1) had no literacy skills, 23.5% (n=8) had limited and 73.5% (n=25) had good literacy skills. 56% (n=19) gave feedback on their experience. For 23.5% (n=8) it strongly mattered that they had this option. For the remainder, they were indifferent, as they were fluent in both languages.

Conclusion

We identified that for a proportion of our patient cohort having CGA conducted through Irish was of importance. Ancillary benefits included better understanding of interventions such as deprescribing and brain health techniques when communicated through their primary language.
Hypertension in Older Frail Adults in an Integrated Care Hub -What is the Guidance for Management in this Cohort?
Authors: Ryan Siobhan , Ryan Sheila , Lynch Paula , Mathai Vimal , Alamin Mohammed , Shanahan Elaine , Bourke Bill
Published: September 2024

Background

The current European Society of Hypertension (ESH, 2023) guidelines suggest specific recommendations for very old or frail patients; to maintain an office systolic blood pressure (OSBP) between 140 to 150 mmHg. A reduction of treatment could be considered in these patients with a low OSBP (<120 mmHg) or in the presence of severe orthostatic hypotension or a high frailty level.

Methods

We completed a retrospective chart review of patients 80 years and older, who were referred for frailty and a falls assessment, from November 2021 to April 2024. During the chart review we examined the OSBP recordings for these patients to examine our practice. We explored the medication profile of patients who had an OSBP <120mmHg and >150mmHg. The agents used were ACE inhibitors, Angiotensin Receptor Blockers, Calcium Channel Blockers, Beta Blockers, Diuretics and Alpha Blockers.

Results

The charts for 52 patients met the criteria and were retrieved for review. The average age was 87 years (range 80-96). 3/52(6%) had a SBP < 120mmHg. 27/52(52%) had OSBP between 120 and 149 mmHg. 22/52(42%) had an OSBP >150mmHg. We examined the medication profile of those patients who had an OSBP <120 mmHg. 2/3 patients were on three agents and 1/3 patient was on two agents. Looking at the OSBP profile of those patients who had an OSBP >150mmHg. 6/22(27%) patients were on three agents, 3/22(14%) were on two agents, 12/22(54%) were on one agent and 1/22(5%) were on no antihypertensive treatment.

Conclusion

From our data we found 6% of our patients were over treated for blood pressure while 42% had uncontrolled OSBP readings. We are conscious of deprescribing in older fallers, but further prescribing may be necessary to achieve published targets as per the ESH guidelines. Further research needs to examine the prevalence of white coat hypertension in our cohort.
As Fit as a Fiddle
Authors: Davis Aisling Jane , Doyle Cliona , O'Kane Aoibhean , Smith Finola , Doran Arthur , Hilery Patrick , Namara Rosa Mc
Published: September 2024

Background

The EDITH (emergency department in the home) team is an alternative pathway for older adults requiring emergency care. The team consists of an occupational therapist (OT) and a doctor who provide specialized geriatric care in patients' homes thus negating the need for an emergency department (ED) presentation. The patients' profile is typically frail older adults however this service can be accessed by any person over 65 years within the catchment.

Methods

Clinical frailty scales (CFS) are routinely completed as part of the OT assessment process. A review of the OT logbooks and electronic healthcare records was completed over an 18-month period. The average CFS was 6 however 11 patients with a CFS of 1 or 2 were identified. The health care records was analysed to identify similarities in this subset patient population group.

Results

It was found that none of these patients had formal supports, and none were living in residential care. The age range was 65 to 90 years old. None of these patients required an onwards referral to community services or provision of OT equipment. Presenting complaint breakdown: explained falls (2), DVT (2), Blood pressure issues (2), pain (2), catheter (1), covid (1), INR problems (1). At 3 months post EDITH review it was found that no patients had a re attendance to ED.

Conclusion

Patients with a low level of clinical frailty make up a very small sub set of the general EDITH patient population. These patients appear to be living independently within the community and do not require extensive OT input. Their presenting complaints appear to be predominately isolated medical events as opposed to chronic medical issues.