bluuebunny/crossref_metadata_2025_split huggingface dataset:
43 A Model of Interdisciplinary Working to Enhance the Care of Residential Home Patients
Authors: Goodwin E , Bacarese-Hamilton T , Steel A , Patel A 
Published: February 2020

Abstract

Introduction
291,000 patients in the UK live within the care home setting. The King’s Fund reports that the average residential home patient is an 85-year-old female with a 12-30 month life expectancy. Care needs are complex with six or more diagnosed conditions, seven or more prescribed medications and a combination of physical frailty, disability and mental health conditions. In line with the NHS Long Term plan 2019 the Care Home project sought to promote ageing well through interdisciplinary working.

Aims
Provide cost neutral interdisciplinary review of care home residents Review the medication of all residents Review resuscitation status and initiate anticipatory care plans for appropriate residents To further the education and professional relationships across primary, secondary and mental health interface. Reduction of transitions between care settings for residents.

Methods
12 sessions in 1 care home over a year (2018-2019) Team consisted of GPs, Geriatric Registrars, Old Age Psychiatry Registrar, care home staff and CCG pharmacist 2-4 patients per session chosen on the basis of complex physical and/or psychological needs Format of session consisted of: o Pre-assessment discussion of patient o Interdisciplinary patient review o Debriefing and formulation of management plan Sessions concluded with teaching from the different disciplines.

Results
We reviewed 25 residents with an average Clinical Frailty Scale score of 7. 100% patients had a medication and psychiatric review. 100% had review of DNAR status with 40% increase in DNAR forms completed. There was a 60% increase in anticipatory care plans initiated. There was a reduction in acute admissions from the care home with a resultant cost saving of over £45,000. 100% of participants would strongly recommend the project and reported improved relationships. 90% of care home staff thought the project was beneficial to the residents and staff felt more supported.

Conclusions
Interdisciplinary working within the patient’s own setting provides patient centred care, promotes sharing of professional expertise, enhances clinical skills and builds professional relationships. This model of project is easily scalable and is a cost-effective way of providing high quality care for patients in their own residence.
46 The Accuracy of Frailty Scoring and Uptake of Comprehensive Geriatric Assessment (CGA) In Patients Living with Frailty Admitted Through the Emergency Department (ED) In Wythenshawe Hospital
Authors: Murphy A , Briggs S 
Published: February 2020

Abstract

Introduction
Frailty can be defined as a state of physiological decline related to ageing and its identification is crucial for subsequent management. A Cochrane review found that CGA significantly reduces mortality and institutionalisation at 6 months.1 Published standards for the hospital state that patients with a clinical frailty score (CFS) of ≥7 should be seen by a geriatrician within one hour of presentation to hospital. We investigated if this was met.

Methods
Assigning a CFS to all patients ≥65 was introduced to ED triage in November 2018. Patients scored as ≥4 were identified over a 10-day period. We assessed the accuracy of ED based frailty scoring, subsequent hospital wide CGA uptake and investigated if patient’s frailty scores influenced this. We also compared CGA uptake across specialities.

Results
Over 10 days, 230 patients entering ED were identified as frail. 33% of patients received CGA. On average, it took 18 hours for a patient to get CGA, and 23 hours for a patient with a CFS ≥7 to receive CGA from a geriatrician. The CFS had no influence on them receiving CGA. Surgical specialities were better than some medical specialities in assessing frailty. 38% of the patient’s CFS were correct.

Conclusions
The hospital is falling short of the standards set out by the department; suggesting that changes need to be made to the process of CGA. There is currently no hospital-wide proforma for CGA; collecting data on the process is laborious and the triggers for CGA are not working as they should. Adding CGA to the hospital EPR would improve this. Highlighting the patients CFS will encourage referral for CGA. Specialities such as cardiology and respiratory can learn from the systems for the recognition and assessment of frailty in place on surgical wards.

Reference
1. Ellis, et al. Cochrane Review 2017.
49 Introducing A Geriatrician Into A Renal Service to Aid Decision-Making and Advance Care Planning
Authors: Aylett V , Mooney A , Kime Z , Windass A 
Published: February 2020

Abstract

Introduction
Over the past 30 years the population of end-stage renal disease (ESRD) patients has aged; the average age of starting dialysis is 67. Many have significant comorbidities, and the benefit for frail patients or those over 80 starting dialysis is uncertain.
Despite this, when older patients with ESRD are admitted to hospital as an emergency, few have an advance care plan or resuscitation decision. The Nephrologists in our hospital recognised that many of these patients might benefit from an out-patient Geriatrician review.

Methods
The Renal Low Clearance Clinic in Leeds assesses patients with ESRD who are approaching dialysis or conservative management. A Geriatrician was established within this setting, seeing patients in an alternate-week clinic. A collaborative approach with the pre-dialysis nurses led to identification of appropriate older patients. This work has been described elsewhere (KimeZ et al, abstract accepted for UK Kidney Week 2019.)
Use of comprehensive geriatric assessment (CGA) allowed for sensitive exploration of long-term goals, with discussions regarding plans in relation to renal replacement therapy and resuscitation, as well as generating continence, falls and memory clinic referrals. Where possible, family were involved.

Results
43 patients had completed encounters, with an average age of 79 (range 67-90.) The median Rockwood Frailty Score was 4 (range 1-7). 29 patients were seen at one visit, the rest requiring 2 or 3 appointments.
Prior to the encounter, only 2 patients had a DNACPR decision in place. Following this, 42 patients had had a resuscitation discussion and 18 patients chose DNACPR. Initially, only 7 patients had already chosen conservative management; this increased to 21 following discussions, including 7 who had previously opted for dialysis, the other 7 having been undecided. Those choosing conservative management were referred on to a specialist Renal-Palliative Care clinic.

Conclusions
Introducing a Geriatrician into the Low Clearance clinic has been welcomed by Renal colleagues and the effect has been apparent, with increasingly challenging patients being referred. CGA and advance care planning is feasible in this setting, which should have beneficial outcomes for patients in the longer term.
59 A Qualitative Study Evaluating Patient Education in the Pre-Operative Pathway for Elective Hip and Knee Arthroplasty at A Major London Teaching Hospital
Authors: Abbass R , Ahmed H , Asinger S , Haq I , Rahman A , Sharif F , Tonner E 
Published: February 2020

Abstract

Introduction
Rising demands for hip and knee arthroplasty have been met with incremental advancements in both implant design and surgical technique. Despite these advancements in the intraoperative setting, the preoperative pathway has remained largely unchanged. The resulting ineffective demand management and improper patient optimisation through education and engagement, has contributed to long waiting times and increasing surgical cancellations. This has in turn lead to both patient distress and the disruption of clinical workflow.

Aims
This study aimed to investigate the effectiveness of patient education in the pre-operative pathway for elective hip and knee arthroplasty, at Imperial College Healthcare NHS Trust, from the perspective of key clinical stakeholders.

Methods
16 Semi Structured Interviews were conducted with Healthcare professionals (HCPs) along the preoperative pathway. These included GPs, Orthopaedic Surgeons, Nurses, Anaesthetists, Orthogeriatricians, Occupational Therapists and Physiotherapists. Interviews were recorded, transcribed and thematically analysed. Sampling continued until information redundancy was reached.

Results
HCPs stressed that patient education lacked engagement & effectiveness. Whilst joint school (an MDT run seminar) is in place for patients before surgery, it was resource intensive meaning sessions were infrequent and often overcrowded.
Furthermore, not all patients were invited/attended joint school as a result of problems with scheduling and transport. Of those whom did, information retention was identified as a problem, highlighted by patients not bringing in medication, and failing to follow fasting instructions, leading to cancellations on the day of surgery. A significant proportion of elderly patients also needed additional and continued support in understanding and interpreting information, a key issue that was not addressed by traditional joint school.

Conclusions
This study has provided a more in-depth analysis of patient education in the pre-operative pathway revealing inadequate tailoring, and delivery of education material particularly for the older patient. Both timing, content and frequency of patient education could be improved in order to improve quality of care and reduce cancellations in turn improving the management of demand for orthopaedic services. Future studies may want to evaluate the use of digital technology in this area of the pathway in efforts to overcome these issues.
60 Post Inpatient Fall Medical Assessment (PIFMA) Performa Quality Improvement Project
Authors: Chan M , Tan C W , Mathew P 
Published: February 2020

Abstract

Introduction
Inpatient falls are the most commonly reported patient safety incidents and in the United Kingdom, there are 250,000 reported falls per year 1. A rapid response report (RRR) issued in 2011 by the NPSA highlighted need for improvement in identifying fractures and neurological observations. These figures reflect significant implications to patients’ health and financial burden to the NHS.

Aims
To improve assessment and documentation of inpatient falls assessment.

Methods
Two PDSA cycles were completed. First PDSA cycle established a baseline of post fall assessment and documentation in which raising awareness and teaching (RAT) to junior doctors was done. Second PDSA cycle identified room for further improvement and post inpatient fall medical assessment (PIFMA) Performa was developed to aid assessment and documentation for use of junior doctors. Feedback regarding the usefulness of the PIFMA Performa was collected via survey.

Results
The RAT intervention involved 30 patients of the Elderly wards in November and December 2017 and the PIFMA intervention involved 29 patients in all Medical wards in January and February 2019. The PIFMA Performa improved the time taken to review patients as per doctors survey. On comparing the RAT against PIFMA Performa interventions, documentation improved in the categories of physical examination (from 80% to 97%), neurological observations (from 49% to 98%), medication review (from 53% to 83%), and measuring lying standing blood pressure (from 83% to 90%).

Conclusions
Feedback from junior doctors states that the PIFMA Performa was certainly a very useful guidance tool and help to speed up documentation. These improvements only translated if junior doctors utilize the PIFMA Performa and so this is now being implemented in the trust policy. Further PDSA cycle can reassess if improvements truly represent the population cross-section.

References
1. The incidence and costs of inpatient falls in hospitals (2017), NHS improvement.
2. National Patient Safety Agency NPSA/2011/RRR001 (13 January 2011).
61 Targeting Elderly Patients on Inhaled Corticosteroids for Respiratory Optimisation
Authors: Wicks L , Kubler A , Robinson P 
Published: February 2020

Abstract

Introduction
Inhaled corticosteroids (ICS) are associated with increased rates of pneumonia, fracture and diabetes. ICS have limited short and long term benefits in COPD, and cessation of steroids in selected patients has been proven safe. We observed that a large proportion of inpatients in the geriatric service were prescribed ICS, and we aimed to review the reasoning for this and introduce a program of respiratory review in order to optimise care in these patients.

Methods
We conducted a retrospective audit of patients discharged from a geriatric service over a 3 month period. Sequential discharges were assessed for the presence and type of inhaled therapies, the documented diagnosis. After identifying high rates of inhaled therapy usage, we undertook a series of quality improvement interventions aimed at optimising respiratory care in these elderly patients. This included a guideline based protocol for reviewing respiratory diagnoses and prescriptions.

Results
In the retrospective analysis, 67/297 (22.5%) patients were discharged on inhaled therapy. 55/67 (82%) were discharged on an ICS, of which 20/67 (36%) were on high doses, equivalent to &gt;1000micrograms of beclomethasone. Very few of these patients had evidence of inhaled therapy review during admission. 15/55 of these patients were given a discharge diagnosis of pneumonia; whilst only 6/55 were admitted with an exacerbation of their COPD. Our preliminary data suggest that a single paged protocol aimed at improving adherence to best practice lead to practice change: Dose modification has occurred in 50% of patients on ICS, leading to a reduction in steroid burden, and an annual reduction in prescription costs of £75 per patient reviewed. None of these patients have been re-admitted with respiratory exacerbations.

Conclusions
By introducing measures to assist in the review and modification of inhaled therapies, we were able to change practice. The alteration in practice led to reduction in prescription costs, and a reduced burden of inhaled corticosteroids. We propose that widespread encouragement of geriatrician led respiratory review could lead to harm reduction and cost saving in elderly inpatients.
64 Evaluating the Acute use of Rotigotine Patch for Dopaminergic Replacement in An Inpatient Population
Authors: Ibrahim H , Cavanagh A , Richfield E W 
Published: February 2020

Abstract

Introduction
Rotigotine, a trans-dermal dopamine agonist (DA), can be used acutely for inpatient populations and is an option in end of life (EoL) care for people with Parkinson’s disease (PD) where enteral (oral or naso-gastric) routes are no longer available or appropriate. Concerns regarding acute use of DAs in hospital include: i) difficulty achieving dopaminergic equivalence; ii) promotion of delirium; and iii) promotion of terminal agitation at EoL.

Methods
We retrospectively evaluated acute inpatient Rotigotine use in a UK teaching hospital. Prescriptions between January-June 2018 were identified from the pharmacy database and relevant inpatient records were analysed. The OPTIMAL calculator was used as a gold standard for dopaminergic conversion.

Results
33 eligible inpatients were identified. 13 (39%) patients were prescribed the recommended dose of Rotigotine; 7 (21%) higher and 13 (39%) lower than recommended dose. Of 22 (66%) patients with delirium, 18 (82%) inappropriately received the higher dose. 12 (36%) patients developed new or worsening delirium; and 6 (18%) developed new or worsening hallucinations. 19 (58%) patients were dead at time of evaluation with median survival of 22 days (range 1-207). For patients prescribed Rotigotine for EoL (n=13), median survival was 15 days (range 1-62); for patients not prescribed Rotigotine for EoL (n=20), median survival was 81 days (range 6-207). Of 13 (39%) patients prescribed Rotigotine for EoL, 9 (69%) had evidence of terminal agitation.

Conclusions
Acute conversion to Rotigotine remains problematic, despite availability of validated tools. Inappropriate dosing may precipitate or worsen delirium. Acute prescription of Rotigotine appears to act as a proxy marker for poor prognosis and could be a red flag for triggering advanced care planning. Little is published regarding use of Rotigotine at EoL, this data raises concerns regarding risk of terminal agitation and is an important area for further study.
71 Changes in Muscle Strength in Older Patients During Hospitalisation: A Prospective Repeated Measures Cohort Study
Authors: Hartley P , Romero-Ortuno R , Wellwood I , Deaton C 
Published: February 2020

Abstract

Introduction
Hospital associated deconditioning is a well-established phenomenon. Whilst mechanisms are not well understood, one is thought to be skeletal muscle wasting and/or loss of muscle strength. The primary aim of this study was to investigate changes in knee-extension muscle strength in older patients during and after an acute-hospital admission. We also aimed to explore the potential contributions of frailty, acute-illness severity and sedentary activity, with changes in knee-extension strength.

Methods
This was a prospective repeated-measures cohort study. Measurements of muscle strength and functional mobility were taken at recruitment, on day 7 of admission (or at discharge if earlier) and again 4-6 weeks post-hospitalisation. During the first 7 days of admission, daily measurements of muscle strength were taken.

Results
We recruited 70 participants, of which 65 had at least one repeated measure in hospital. Median age was 84 years, and participants participated in the study for a median of 6 days whilst in hospital, on average participants were ‘active’ for less than 4% of the day. Knee-extension strength significantly reduced by approximately 11% during hospitalisation, but no significant changes occurred post-hospitalisation. A repeated-measures mixed model included 292 observations from 62 participants and showed a significant decrease in the reduction in muscle strength as patients' sedentary time decreased on days 2 to 7 of the study. Additionally, the model showed that a higher frailty score, higher baseline knee-extension strength, lower baseline c-reactive protein levels were associated with greater loss in knee-extension strength during hospitalisation. Association between change in functional mobility after hospitalisation and change in knee-extension strength during hospitalisation was non-significant.

Conclusion
Our findings provide an important link in understanding the mechanisms and relative contributions of risk factors to hospital associated deconditioning. Further research is needed to confirm these findings and examine the impact of reducing sedentary time on muscle strength during and post-hospitalisation.
72 Prevalence of Reported and Unreported Vertebral Fractures in Ctpas in Older Adults Above 75 Years
Authors: Jones L , Singh S , Edwards C , Goyal N , Singh I 
Published: February 2020

Abstract

Introduction
Identifying vertebral fractures is prudent in the diagnosis of osteoporosis as they occur early in this hidden condition. Unfortunately, due to their unspecific presentation, only 25% are clinically recognised. Computerised Tomography Pulmonary Angiogram (CTPA) are frequently requested to confirm pulmonary thromboembolisms, but could also aid in detecting clinically silent vertebral fractures. Current literature suggests that less than one-third of incidental vertebral fractures are reported. The aim of this study is to measure the prevalence of vertebral fractures in CTPA and its relevance to clinical outcomes.

Methods
This is retrospective observational study based on the analysis of existing CTPA for acutely unwell patients admitted to medical assessment unit or A & E across three acute sites within Aneurin Bevan University Health board, Wales, UK between January and December 2015. All CTPA reports were reviewed for fragility factures and CTPA images were reassessed for any unreported vertebral fractures. Age and gender were recorded for all patients. Analysis was done for all patients in respect to subsequent fragility fractures and mortality. Difference of proportion test was used to compare two groups with and without vertebral fractures.

Results
179 CTPA were reviewed, 161 patients were included for further analysis. 14.3% (n=23/161) were reported to have a vertebral fracture, however only 8.7% (n=14/161) of reports used the correct terminology of ‘fracture’. On subsequent review, an additional 24.2% (n=39/161) vertebral fractures were noted. Therefore, overall prevalence of vertebral fractures was 38.5% (n=62/161). Only 9.1% (n=9/99) of patients without a vertebral fracture developed a subsequent fragility fracture. In comparison, 22.5% (n=14/62) of patients with a previous vertebral fracture sustained a new fragility fracture over next 4 years and this was significantly higher (p = 0.017). Overall mortality over 4 years follow-up was significantly higher for patients with vertebral fractures (64.5%, n=40/62) as compared to those without fractures (43.4%, n=43/99, p = 0.009). Only 48.4% (n=30/62) received osteoporosis treatment.

Conclusions
Vertebral fractures could be underreported by radiologists, likely due to human factors as they might be concentrating on the clinical scenario to exclude a pulmonary embolism. However, considering a significant higher mortality in patients with underlying vertebral fracture, it justifies that radiologists could be asked to examine sagittal view in the bone window for possible underlying vertebral fractures, to ensure osteoporosis is treated to guidance.
86 Fear of Falling as Measured by the Falls Efficacy Scale International Indicates Gait and Balance Abnormalities in Community Dwelling Older People
Authors: Gibbon J , Trundle H , Green D , Strassheim V , Linsley M , Parry S W 
Published: February 2020

Abstract

Background
Falls are common in community dwelling older people, and gait and balance abnormalities (GABAb) are a key modifiable risk factor, through strength and balance training. In addition, there is a strong relationship between fear of falling (FoF) and GABAb , though Falls Efficacy Scale-International version (FES-I) scores have never been examined in this context. Our aim was to determine whether FoF, as measured by the FES-I, is associated with GABAb, as determined by commonly used gait and balance tests.

Methods
Consecutive patients attending our community falls prevention service completed FES-I questionnaires, and had Gait Speed (GS), Five Times Sit to Stand (FTSTS) and Timed Up and Go (TUG) tests assessed as part of a multifactorial falls prevention assessment. Cut-offs for falls risk are provided in the table. Sensitivity and specificity values for a 16-item FES-I cut-off score of 23.5 (&gt;23 signifying significant FoF) were evaluated using the area under a receiver operating characteristic curve (AUROC), along with positive and negative likelihood ratios (LR+/LR-).

Results
There were 991 participants, 352 male, 639 female, mean age 74.5 years, mean FES-I score 28.7 and 57.0% had experienced at least one fall in the previous year. Gait and balance test scores were moderately associated with FoF per FES-I ≥23.5 as shown in the table. Specificities and sensitivities for all three are similar to commonly used diagnostic tests such as exercise testing versus coronary angiography for coronary artery disease.

Conclusions
FoF as measured by the FES-I is associated with scores on commonly used gait and balance tests that indicate a high risk of falling. This study highlights the potential of using FES-I as a screening tool to identify community dwelling older adults at risk of falling who may benefit from strength and balance training rather than relying on physical tests that are rarely performed outside falls clinics and physiotherapy departments. This application may have utility both in opportunistic individual screening and community screening programmes.