bluuebunny/crossref_metadata_2025_split huggingface dataset:
21 The Jean Bishop Team, Hull: A New Model of Care for Comprehensive Geriatric Assessment of the Frail Population
Authors: Athorn K , Folwell A , Harman D , Kar S , Windass L 
Published: February 2020

Abstract

Introduction
Hull CCG recognised system’s over-reliance on reactive, hospital care and workforce deficits, requiring a modernised service model for frail older people that moved from individual provider focus to system-wide perspective, with emphasis on proactive care.

Methods
Electronic Frailty Index (eFI) in primary care system identified 3,200 out of 300,000 Hull residents Hull with severe frailty. Recruited 9 GPs with extended role in older people’s care and Advanced Nurse Practitioners to support 4 Community Geriatricians. Redesigned roles for pharmacy, social services and non-clinical care coordinator teams. New therapy roles created, multiple third sector organisations involved, including carer support, and purpose-built location with older people in mind.

Interventions
Structured and anticipatory comprehensive geriatric assessment of all 3200 residents (either at home or in care homes) by the multidisciplinary multiagency team. Pre-assessment home visit by support worker to complete patient concern’s questionnaire. Dedicated patient transport and one-stop multi-disciplinary team assessment in one building. Proactive discussion of RESPECT and advance care planning, electronic personalised care plan delivered with system-wide record sharing across providers, Same day basic diagnostics available. Complex care coordinators ongoing support in community. Multi-disciplinary outreach to care homes and truly housebound.

Results
99.7% patients and carers extremely likely/likely to recommend the service 21,000 interventions for 2,500 patients seen since June 2018 Majority of patients moderately frail by Clinical Frailty Score Average saving on drug costs - £110.17 /patient/year 15% reduction in ED attendances, 29% reduction in emergency admissions Patients’ survey: adequate time and opportunity to discuss health problems/concerns, felt informed and empowered during consultation and in future planning Very high levels of staff satisfaction

Conclusions and future
Innovative high quality, cost-effective new model of care delivering improved patient care and experience with emphasis on proactive care and future planning High levels of patient and staff satisfaction Future expansion with disease specific teams including COPD, parkinsonism and diabetes and targeting moderately frail by eFI. Redesign of community services with improved integration across teams and providers can be a blue-print for other services.
22 Design and Implementation of A Nutrition Clinical Pathway for Patients with Fractured Neck of Femur
Authors: Kingdon J , Aadan H , Husain S , Atkinson C , Thomson C , Braude P 
Published: February 2020

Abstract

Background
Patients with a fractured neck of femur (FNOF) are commonly malnourished pre-admission, have reduced oral intake in hospital and a hypermetabolic state up to three months postoperatively (E Paillaud 2000). Malnutrition is associated with functional deterioration, higher morbidity and mortality.
Evidence suggests nutritional supplementation post-surgery can reduce postoperative complications. As a result, nutritional assessment is included in the National Hip Fracture Database best practice tariff (Avenell, Cochrane Database of Systematic Reviews 2016).

Introduction
Our aim was to design and implement a clinical pathway for patients with FNOF to identify malnutrition and provide appropriate nutritional support.

Intervention
A retrospective audit of 25 patients was completed to understand baseline rates of assessment, prescription of supplements and referral to dietetics. Using these data meetings were arranged to develop a clinical pathway. Key stakeholders included dietetics, orthopaedic surgeons, geriatricians, physiotherapists and nurses. The pathway was evaluated and optimised with two Plan-Do-Study-Act (PDSA) cycles looking at 25 patients each time.

Results
Baseline: 79% received a nutritional assessment, 32% had nutritional supplements prescribed and 36% (n=9) met criteria for referral to a dietician, of which 55%were referred. However, an additional 5 referrals were made to dietetics for patients who did not meet criteria, a 50% inappropriate referral rate.
PDSA cycle 1: increased nutritional assessment (85%), increased nutritional supplements prescribed (92%), decreased inappropriate referrals to dietetics (43%).
PDSA cycle 2: increased nutritional assessment & nutritional supplements prescribed (100%), increased inappropriate referrals to dietetics (80%).

Conclusions
The implementation of a nutrition pathway has led to increased identification and treatment of malnutrition, which has in addition improved accrual of the best practice tariff. However, greater number of inappropriate referrals have been made to dietetics. This is partly attributed to difficulty weighing patients on admission, and where no weight is inputted on the Malnutrition Universal Screening Tool a “High Risk” score is generated triggering a referral. We are now looking at alternative methods to obtaining a weight such a mid-upper arm circumference.
26 Empowering Nursing Staff to Identify Delirium and Provide Intervention for Older Patients Post Transcatheter Aortic Valve Implantation Procedure in A Cardiology Ward: A Quality Improvement Project
Authors: Bulled E 
Published: February 2020

Abstract

Background
Delirium is a common condition, particularly in the hospital setting, and has associated poor outcomes. Transcathether Aortic Valve Implantation provides a less invasive intervention for the treatment of Aortic Stenosis and this patient group often presents with increased risk factors for delirium. Nurses are in a key position to identify and manage delirium with literature suggesting educational interventions can support this.

Aim
The aim of the quality improvement project is to empower nursing staff to identify delirium and provide intervention for older patients post Transcatheter Aortic Valve Implantation procedure in a cardiology ward.

Methods
A driver diagram supported local problem analysis and stakeholder analysis identified those required to support change. The Behaviour Change Wheel and COM-B system identified behaviours required for change and guided intervention design. Plan, Do, Study, Act cycles directed project planning and the implementation of interventions.

Results
Nurse knowledge of delirium scores increased for ten out of twenty-three nurses or 43.7% post delirium training session. Nurse self-perceived confidence increased in three aspect of delirium care: recognising signs and symptoms, undertaking screening and delivering interventions for the management of it. All nurses were either likely or extremely likely to recommend both delirium training sessions provided to their colleagues. When comparing the data prior to and during the QIP intervention, an increased in identification and management of delirium was demonstrated. However demonstrating if there is a direct correlation between nursing staff attending delirium training sessions and patients having increased identification of delirium and management interventions has been more difficult to ascertain.

Conclusions
The Quality Improvement Project was well received and useful in raising awareness of delirium and enhancing nurse knowledge and confidence in delirium care. Next steps involve additional delirium training and data collection to explore the impact of the interventions further. Feedback has been positive and discussions about potential spread to other contexts and care pathways have taken place.
27 Re-Audit of Orthostatic Blood Pressure Measurement to Prevent Falls and Fall-Related Complications for Geriatrics Inpatients from A Secondary Care Hospital
Authors: Sultana Z , Sarda P , Ang S Kim 
Published: February 2020

Abstract

Introduction
Orthostatic Hypotension is a common cause of falls leading to injury and morbidity in older adults. In the National Audit of Inpatient Falls 2015 audit, only 16% of 4846 patients had an orthostatic Blood Pressure (L/S BP) recorded by their third day in the hospital. There is also variation in the understanding of how doctors and nurses perform orthostatic BP. This could have adverse effects on detection rates and accuracy of the procedure resulting in misdiagnosis. As a result, the Royal College of Physicians (RCP) has released guidance on Orthostatic BP measurements to perform the standardising practice and improving accuracy. The purpose of this quality improvement project (QIP) is to work on the action plan from the orthostatic BP measurement QIP has done in 2017, by introducing laminated guidelines in patient’s notes and re-audited in 2018 to record any improvement. The re-audit of 2018 showed remarkable improvement but still not as equal as the gold standard as RCP. Therefore, the second loop of re-audit performed in 2019 in major Geriatrics wards and other wards while involved larger sample (patient) numbers. We used four questioners as the audit proforma.

Methods
Wards were audited to find out whether orthostatic BP is measured as per RCP guidelines. Afterward, a laminated copy of the RCP recommended method of measuring orthostatic BP was put into all Early Warning Score ‘Observation’ folders with a sheet designed specifically for recording Orthostatic (L/S BP). The procedure of L/S BP measurement was re-audited after the intervention to find out changes in performing orthostatic (L/S BP) (as per RCP guidelines).

Results
There is a remarkable improvement of outcome reveals in the second loop of re-audit. Regarding RCP guideline compliance, it is 93.33% which is closer to the gold standard. And in case of symptoms identification and documentation, it is 100%, which is equal to the RCP gold standard.

Conclusions
Inclusion of guidelines in notes improves investigation; inclusion of supplementary recording sheet improves documentation. Re-audit reflects the remarkable improvement to compliance with RCP guidelines in measuring Orthostatic BP measurement and patient’s symptoms documentation.
29 Geriatric Emergency Medicine (GEM) Bootcamp and Bootcamp Bitesize Training
Authors: Sendall C , Williamson M , Solomon C , Belcher R 
Published: February 2020

Abstract

Introduction
In 2016 we ran a successful pilot of Geriatric Emergency Medicine (GEM) Bootcamp at Imperial College Healthcare Trust. This has developed into an annual regional conference which to date has been attended by over 440 delegates. This year we have been able to expand GEM Bootcamp to offer smaller ‘Bitesize Bootcamps’ with tailored learning for individual organisations, with more than 100 delegates already having accessed this resource.

Methods
In developing the curriculum for GEM Bootcamp and Bootcamp Bitesize we engaged a significant range of local healthcare providers. We undertook a learning needs analysis, which surveyed the target audience- specifically looking for self-reported gaps in knowledge- as well as analysing data from incidents, complaints and compliments. This allowed us to identify areas which there was opportunity for learning as well as ensuring a personalised curriculum

Results and conclusions
GEM Bootcamp feedback was overwhelmingly positive, with 100% of delegates stating they would recommend the day to colleagues. The relevance to practice was rated 4.4/5 with many positive comments about the opportunity to meet many interested people, generate conversations and raise awareness of frailty. The self-reported improvement of knowledge was from 2.95/5 pre-course to 3.89/5 post course.
To date we have delivered Bitesize Bootcamp to a local nursing care centre (which accounts for 50% of the admissions from care homes to the ICHT), London Ambulance Service (LAS), acute medicine and medicine for the elderly from a local trust, ICHT A&E nurses and Capital Nurse trainees. All bitesize training delegates self-reported an increase in their frailty knowledge. On average over the 5 bitesize sessions delegates reported an improvement from 3/5 pre-training to 4.1/5 post training. The development of links with local partners and the delivery of a consistent message about best practice in frailty have also been valuable outcomes
32 Medicine for Older People Liaison Service to Acute Surgery Reduces Length of Stay of Older People Living with Frailty
Authors: Everett R , Patel H 
Published: February 2020

Abstract

Background
Of people admitted to the acute surgical unit (ASU) only 23% of them are aged over 70. However the number of bed days they occupy are disproportionate to this; comprising 48% of the total bed days. The average number of bed days rises exponentially with age, with those aged under 70 averaging less than two days; those aged 80 averaging approximately 4.5 bed days and those aged over 90 approximately 7 bed days.
This disparity was recognised and a Medicine for Older People (MOP) liaison team comprising consultant geriatrician and Advanced Clinical Practitioner in Frailty starting working with the acute surgical team in November 2018, initially providing support two days a week, increasing to 5 days in March 2019.

Methods
The MOP liaison team meets with the acute surgical team each morning identifying and discussing relevant patients; those identified as living with frailty with associated complexity and uncertainty. This group of patients is then reviewed by the MOP liaison team utilising the principles of the comprehensive geriatric assessment to formulate a person-centred plan. Plans are discussed and coordinated with the surgical, nursing and therapy teams utilising a multi-disciplinary/ multi-professional approach.

Results
Length of stay is the main outcome measure and readmissions are monitored. Data on admission length and readmissions was analysed from April 2018 and has continued following commencement of the liaison service.
Primary results- Length of stay has reduced from 4.4 to 3.3 days on average for all over 70-year-olds admitted to the ASU team. Whilst admission rates have dropped across all age ranges the biggest reduction in readmissions is among the over 80-year-olds with an almost 50% reduction as opposed to a 33% reduction in the under 70 age group

Conclusions
Proactively managing the admissions and discharges of patients with frailty allows them to receive the right care at the right time in their period of crisis and shortens their admissions by approximately 25%.
33 Improving Mortality with An Integrated Model of Care for Cervical Spine Fracture in Patients Over 75 Years Old
Authors: Mahmood R , Negasan C , Manzoor A , Enwere P , Arnada-Martinez A , Walters H , Yeong K , Lisk R 
Published: February 2020

Abstract

Introduction
Cervical spine injury is a potentially life threatening trauma. Given the increase in the number of patients presenting to the emergency department (ED) who are elderly and who have fallen and sustained trauma, it has become ever so challenging to manage this cohort of patients. In addition to diagnostic challenges in the elderly population, a robust, integrated care pathway and comprehensive geriatric assessment with involvement of a geriatrician is essential to provide effective care to these patients who require cervical collar after cervical spine injury to prevent morbidity and mortality.

Intervention
Data was gathered about the patient’s demographics, nature of cervical spine injury, care required from January 2013 till November 2016 (pre intervention) and from November 2016 till October 2017 (post intervention). Current practice was reviewed which showed significant variability in care provision to patients with cervical spine injury including collar care.
An integrated care pathway was designed with involvement of multidisciplinary team (MDT) members to standardise the care of this cohort of patients in our hospital. This included early identification of patients with cervical spine injury, co locating all patients, developing nursing expertise for cervical collar care, sitting up early to prevent complications like aspiration, pressure area care, early nutritional support, training staff in post discharge collar care with developing interface with primary care team. Outcome measures in patients over 75 years including length of stay (LOS) inpatient mortality and at 6 and 12 months were recorded respectively.

Results
Total: 54 patients, average age: 86.6 years

Conclusions
Cervical spine injuries are common in older patients, who are at greater risk of falls and thus sustaining injuries. Early identification and management of these patients in a clinical area with multidisciplinary approach with appropriate expertise is key to reducing LOS and adverse outcome including mortality.
34 Geriatricians in Intermediate Care Settings: A Modern Approach to Geriatric Medicine
Authors: Enwere P , Mahmood R , Aranda-Martinez A , Manzoor A , Wilkinson E , Soliman K , Yeong K , Lawn L , Lisk R 
Published: February 2020

Abstract

Introduction
Due to growing older population with increasing medical complexity and care needs, over-reliance on acute hospitals for care delivery, disconnect between social and medicalised care and challenging national health services (NHS) financial climate, it is essential to provide much of this care to our older patients outside the acute hospital before they reach crisis point. This prevents unnecessary hospital admissions and outpatient referrals especially to our geriatric services. Therefore, newer and innovative care models are required to cater the needs of our aging population especially within the community settings. The North West Surrey clinical commissioning group (CCG) catchment area is divided into three localities, namely SASSE Locality in Spelthorne, Thames Medical Locality in Runnymede/West Elmbridge, and the Woking Locality (Bedser hub) in Woking.
Locality hub model of integrated care led by GP with multidisciplinary (MDT) input along with wellbeing coordinators was introduced to address above issue.

Objectives
Our mission was to find a way to manage the challenges we face from a growing older population within an integrated GP-led community service and in a manner that promotes independence, reduce social isolation, improve patient experience and safely deliver appropriate acute care in the community whilst reducing dependency on regional acute hospitals. A fully qualified geriatrician input was introduced within the hub model at Bedser hub.

Results
Total savings: £16,484, Geriatricians input cost: £16,500 Cost neutral intervention

Conclusions
Newer models of collaborative healthcare within the community dwellings with GP and geriatrician input along with multidisciplinary approach are essential to deliver safe and high quality care to our older population, thus reducing reliance on our ever so stretched local acute NHS hospitals.
Our intervention has resulted in reduction of referrals to geriatric outpatient clinic and enabled us to provide the required care to our older population closer to home. It has also led GPs to build their skills in managing the very frail patients with complex needs safely and effectively. In the long run, the intervention will be cost effective with further projected reduction in referrals.
35 Enhanced Service Through An Integrated New Model of Care in A Buckinghamshire Care Home
Authors: Okoli U , Chimhau S , Nagyova B , Sahni A , Amin S , McGarry S 
Published: February 2020

Abstract

Introduction
Care home residents often have multiple, chronic conditions and are receiving complex treatment regimes. Polypharmacy and medication errors are common. The frequency and quality of medication reviews is variable with limited general practice (GP) capacity to carry out comprehensive reviews.
The initiative used a care home pharmacist, technician, geriatrician and GPs to tackle these issues on an individual and care home level. The objective being to ensure the safe and effective use of medicines for all care home residents. NICE guideline [NG56] recommends reducing pharmacological treatment burden for adults with multimorbidity at risk of adverse drug events such as unplanned hospital admissions. A study by Dilles et al1 found adverse drug reactions in 60% of residents.

Methods
A new interdisciplinary model of care was delivered in a 120 bedded Buckinghamshire care home. Clinical Commissioning Group pharmacist, general practitioners and pharmacy technician reviewed medication for all residents. The most complex individuals were reviewed by the geriatrician and if needed by other multidisciplinary team members specialist.

Results
Overall 115 medications were stopped for 109 residents, with 31 interventions to reduce falls risk and 19 interventions on medication at high risk2 of causing admission. Total cost savings on medicines optimisation, medicines waste and non-elective admission prevented was £35,211. Residents’ care plans were updated to reflect best practice standards.

Conclusions
Future direction of this project focuses on system wide improvements to promote interdisciplinary healthcare professionals work in care homes. The success of this integrated model of care has enabled recurrent funding of pharmacist by the local county council and an additional 42 geriatrician sessions into Buckinghamshire care homes.

References
1. Dilles T, Vander Stichele R, Van Bortel L, Elseviers M. Journal of American Medical Directors Association 2013; 14: 371–6.
2. Pirmohamed M, et al. Br Med J 2004; 329: 15–9 61.
37 Enhance GP-Geriatrician Care Homes Multidisciplinary Team
Authors: Ruiz-Mendoza E , Penart A , Obi I , Addison E , Clark H 
Published: February 2020

Abstract

Introduction
Peterborough Care Home Support Team (CHST) have worked on a small pilot of 4 care homes with a local GP and an interface geriatrician to address the complex needs of the residents within those care homes to improve patient experience, quality of care and reduce attendances and admissions to hospital in a geographical area of 5000 care home beds.

Methods
The multidisciplinary team (MDT) consisted of a General Practitioner, Interface Geriatrician, Pharmacist from the medicine optimisation team and Care Home Support Team member with once a month meeting in the selected Care Home. We measure the impact of our intervention comparing the data predating our intervention comparing 4 selected care homes with high A&E attendances in each period 2017 and 2018.

Results
50% reduction in hospital attendances with £4985.48 cost saving following medication review in the 4 care homes under study.

Conclusions
Commissioners, Local Authorities and Care Home Providers have started to look towards more innovative solutions to improve patient experience, quality of care and reduce attendances and admissions to hospital. Our experience and results aim to consider enhance GP-Geriatrician Care Homes MDT as a good model of care.