bluuebunny/crossref_metadata_2025_split huggingface dataset:
69 Continuous and Regular Live Feedback is Required to Maintain An Improvement in the Quality of Discharge Summaries. Shop 75 +
Authors: Cross H , Evans J , Pederson A , Yidana D , Carey D , Robey R , Vilches-Moraga A , Gaillemin O 
Published: March 2021

Abstract

Background
This quality improvement project aims to improve communication between secondary and primary care at the time of hospital discharge of older patients.

Introduction
Discharge summaries (DS) are a key component of communication between secondary and primary care. Poor quality DS are associated with poorer outcomes in terms of adverse events [1], readmissions [2] and medication errors [3]. There is NICE and AMRC guidance on what constitutes a good DS [4, 5].

Method
Prospective review of DS from a range of wards was completed in August 2017 against a detailed data tool. A random selection of DS from the same wards was audited monthly from November 2017 onwards. A novel live-feedback system was introduced to the same wards in February 2018 so that the teams completing DS received feedback on how well their summaries complied with the recommendations and what areas needed improvement. A change in staffing lead to a break in the delivery of monthly feedback to the ward teams from April to September 2019 when it was re-commenced.

Results
In the majority of areas there has been an increase in the quality of the DS from the beginning of the project until March 2019 when the regular feedback interventions were suspended. There was a decrease in the quality of summaries in July and August 2019, followed by an increase as regular feedback interventions recommenced in September 2019. The aggregate results of the four main components of DS (follow-up actions, medicines, clinical summary, and functional assessment), scored “good” in 13% of DS at baseline, 40% in March 2019, 20% in July 2019 and 31% in October 2019.

Conclusions
The suspension of regular direct interventions resulted in a significant deterioration in the quality of discharge summaries, and this improved quickly after reintroduction of PDSA cycles in key areas. Continuous quality improvement requires uninterrupted focus on regular live feedback.

References
1. Clegg et al. Lancet 2013; 381: 752–62.
2. Samra et al. Age Ageing 2017; 46: 911–9.
3. Romero-Ortuno et al. Age Ageing 2012; 41: 684–9.
70 Improving the Documentation of DNACPR Decisions Following the Transition to Electronic Record Keeping
Authors: Jackson L , Saund J , Donnelly G 
Published: March 2021

Abstract

Background
This quality improvement project was based at The Royal Bolton Hospital across our four Complex Care wards.

Introduction
We have recently transferred to electronic record keeping. At these points of transition there may be an adverse impact on the quality of patient care and safety. We recognised on our own ward there were inaccuracies between the required paper form and electronic documentation of DNACPR decisions. Consequently, we wanted to review and improve the accuracy of our DNACPR documentation to ensure safe and effective patient care.

Methods
To gauge the scope of the problem we audited 87 patient’s electronic and paper notes, with no exclusion criteria. We reviewed whether each patient had a formal resuscitation decision, and if a DNACPR decision had been made whether we met our hospital policy by having:
93% of the 87 patient’s had an active decision regarding resuscitation, with a DNACPR decision documented for 50 patients. Of these 50 patients only 11 had all three forms of documentation. More worryingly, there were discrepancies in the documented DNACPR decisions for 11 patients across paper and electronic records.

Interventions
We escalated our concerns to the Clinical Governance team who sent out a trust wide SBAR highlighting this as an urgent clinical issue. On a directorate level we incorporated DNACPR decision documentation into our afternoon safety huddle and arranged informal teaching for medical, nursing and administrative staff.

Results
Reassuringly, the subsequent re-audit of 90 patient’s notes showed only one patient to have a discrepancy between paper and electronic documentation. We saw an improvement to 98% having paper forms in the right bedside notes and 100% having a documented electronic DNACPR decision.

Conclusion
Through local education and trust-wide dissemination of our expected standards we have seen some improvement. We recognise the importance of maintaining this, and importantly that there is still work to be done. The electronic “Resuscitation and treatment escalation plan” is still rarely completed and provides important information on escalation of care and thus will be the focus of a further educational intervention.
72 Surviving the Epidemic That Confronts Us—Fracture Liaison Service Evaluation Data
Authors: Larcombe T , Lisk R A , Yeong K F 
Published: March 2021

Abstract

Introduction
1 in 2 women and 1 in 5 men over the age of 50 will break a bone and a significant proportion will suffer from osteoporosis.A fragility fracture will double the risk of future fractures. Between 1990 and 2000, there was nearly a 25% increase in hip fractures worldwide. A hip fracture is one of the most devastating, and often terminal, injury for an older person.

Intervention
The Fracture Liaison Service (FLS) captures patients aged 50 and above that present to fracture clinic with possible fragility fractures with the aim to reduce further fracture incidence. Patients are assessed for osteoporosis and recommendations made for treatment.

Results
Here we present the results of our FLS service evaluation after 6 years in operation, using the rate of hip fractures (number of hip fractures/Emergency Department [ED] attendances over 75’s) as a surrogate marker for effectiveness.

Evaluation Summary
Trend analysis of our data indicates a reduction in the number of patients attending the Trust with fractured neck of femur (NOF) despite the increase in ED attendances. This is against the trend nationally where fractured NOF numbers are rising (National Hip Fracture Database, accessed online August 2019).

Next steps
The FLS to attempt to comprehensively capture muscular-skeletal patients and to consider opportunities present to target case finding to high risk cohorts.
77 National Audit of Care At the End of Life (NACEL)—Round Two Findings
Authors: Hibbert D 
Published: March 2021

Abstract

NACEL is a national comparative audit of the quality and outcomes of care experienced by the dying person and those important to them during the final admission in acute and community hospitals in England and Wales. Mental health inpatient providers participated in the first round but excluded from the second round.
NACEL round two, undertaken during 2019/20, comprised:
Data was collected between June and October 2019. 175 trusts in England and 8 Welsh organisations took part in at least one element of NACEL (97% of eligible organisations).

Key findings include
Recognising the possibility of imminent death: The possibility that the patient may die was documented in 88% of cases. The median time from recognition of dying to death was 41 hours (36 hours in the first round).
Individual plan of care: 71% of patients, where it had been recognised that the patient was dying (Category 1 deaths), had an individualised end of life care plan. Of the patients who did not have an individualised plan of care, in 45% of these cases, the time from recognition of dying to death was more than 24 hours.
Families’ and others’ experience of care: 80% of Quality Survey respondents rated the quality of care delivered to the patient as outstanding/excellent/good and 75% rated the care provided to families/others as outstanding/excellent/good. However, one-fifth of responses reported that the families’/others’ needs were not asked about.
Individual plan of care: 80% of Quality Survey respondents believed that hospital was the “right” place to die; however, 20% reported there was a lack of peace and privacy.

Workforce
Most hospitals (99%) have access to a specialist palliative care service. 36% of hospitals have a face-to-face specialist palliative care service (doctor and/or nurse) available 8 hours a day, 7 days a week.
NACEL round three will start in 2021.
82 Person-Centred Emergency Care Outcome Measurement For Older People Living with Frailty
Authors: van Oppen J 
Published: March 2021

Abstract

Introduction
Health outcome goals are the results individuals seek from healthcare. These may incorporate holistic themes including function, mood, and quality of life. People living with frailty have poorer outcomes from even short hospital stays. They benefit from person-centred, goal-directed care over protocol-driven pathway approaches. This could be improved by monitoring attainment of health outcome goals.

Methods
A systematic review for older people’s health outcome goals in emergency care was conducted using narrative synthesis. A qualitative study based on grounded theory expanded the outcome framework to include people living with frailty. People with cognitive and communication barriers were included in semi-structured interviews. Discussions focussed on the events and outcomes sought from emergency care.

Results
Older people’s health outcome goals for emergency care were classified as efficient and comprehensive care, sensitivity towards vulnerability, and person-centred informed care. The importance of understanding individual perceptions was explicit. Research generally recruited based on age rather than physiological and functional state, and did not assess for impact of frailty on healthcare perceptions. The interview study was paused due to the COVID-19 pandemic. Initial results showed a predominance of person-centred and holistic care themes among health outcome goals. Participants’ most common goal for emergency care was relief of symptoms: people often had pain. Participants mostly had severe frailty and wanted their mobility to be assessed, with goals of recovering their functional baseline. While participants had confidence in healthcare professionals and were generally willing to “do as we are told to feel better”, they expected to undergo at least basic tests in order to receive a working diagnosis for their problem. People wanted to understand their illness and for explanations to be communicated to their relatives. Next steps Patient-reported outcome measures (PROMs) for this range of emergency care outcomes are being identified for field-testing in acute settings.
87 Improving the Delivery of Written Communication to Patients Presenting to the Frailty Assessment Service Following A Fall
Authors: Suthermaraj G 
Published: March 2021

Abstract

Introduction
NICE guidelines recommend for healthcare professionals to give patients both verbal and written information when explaining how to prevent further falls at home, how to cope with falls and where they can seek further advice or assistance. Most of the patients seen by the Frailty Assessment Service (FAS) at Northumbria Specialist Emergency Care Hospital (NSECH) will remain at a high falls risk even on discharge. An emphasis should be made on educating patients about how best they can manage their risks at home to prevent further falls.

Method
Over a six month period, data on patients seen by the FAS team was collected by reviewing electronic case notes and the daily patient list to identify presenting complaint and whether a falls leaflet was given on discharge.

Results
Following three cycles of intervention, the rate of falls leaflet distribution to patients discharged following a fall increased from an initial 0% to 24%, then to 55% and finally to 72%. Interventions included, in order; educating all frailty nurse practitioners, amending the daily patient list to include a separate column to prompt ticking if a falls leaflet was given, and notifying all frailty consultants to consider including “falls leaflet” as part of their post-take management plans.

Conclusion
Having a paper information leaflet can be invaluable to patients as it allows them to go away with concrete bits of information that they can always refer back to. This ensures that elderly patients do not face the risk of forgetting any advice given to them verbally during a consultation and written communication would only help to reinforce this instead. In future, it may be helpful to identify if there are reduced rates of re-admission to hospital in patients discharged with a falls leaflet compared to patients discharged without one.
92 Clinical Frailty Scoring Is Crucial For the COVID-19 Era and Beyond
Authors: White L , Tyler A , Samji A 
Published: March 2021

Abstract

Introduction
The COVID-19 pandemic placed a new focus on provision of clinical resources. With high mortality and limited capacity; appropriate decisions to escalate to critical care were vital for just resource allocation but also to prevent harm where interventions would not change outcomes. NICE guidance highlighted Clinical frailty scoring (CFS) as central to the decision-making process. 1, Despite initial criticism, recent evidence has confirmed increasing CFS as an independent risk factor to inpatient mortality in COVID-19.2 We conducted a quality improvement project with the aim of improving CFS documentation at the Royal Free Hospital.

Methods
We reviewed the notes of 71 inpatients over the age of 65 years from 6 wards on 08/05/20–12/05/20 for both a CFS score documentation and clear treatment escalation plan at time points of initial clerking, post-take and following ward admission with an audit standard of 100%. We developed teaching sessions, promoted the CFS mobile application, developed a post-take sticker and an elderly medicine ward admission proforma. We re-audited 66 inpatient notes from the same 6 wards from 25/06/20–07/07/20.

Results
Documentation.of CFS improved from 7% to 17% for clerking and post-take and from 13% to 24% on the ward admission. The number of patients with treatment escalation plans was 50%.

Conclusion
CFS is crucial for the COVID-19 era and beyond. We have demonstrated that increased awareness improves use of CFS, though it is not yet being widely used in escalation decisions. 1. Covid-19 Rapid guideline: Critical Care in adults. NICE guideline [NG159]: https://www.nice.org.uk/guidance/ng159 Accessed July 2020 2. Hewitt J et al (2020): The effect of frailty on survival in patients with COVID -19 (COPE): a multicentre, European, observational cohort study; The Lancet: https://doi.org/10.1016/ S2468–2667(20)30146–8.
95 Lack of Evidence for Reduced Efficacy of Medical Therapy for Heart Failure in Older Adults
Authors: Cox-Smith A , Cooper T , Punjabi P , Barton C , Levy S , Plymen C , Cole G 
Published: March 2021

Abstract

Introduction
There are almost a million people with heart failure (HF) in the UK; the incidence increases sharply with age. Older adults receive less evidence-based therapy with few trials specifically examining therapeutic efficacy in older age groups representative of a contemporary UK HF population. Concern that efficacy is less in older adults may underlie under-prescription. With important recent advances in HF therapy, we reviewed the contemporary evidence base for any signal of different efficacy in older adults.

Methods
We reviewed recent RCTs of medical therapy for heart failure alongside meta-analyses updated with recent therapies including Angiotensin-Neprilysin inhibitors and SGLT2 inhibitors. For those trials in which effect size was presented for age subgroups we compared the effect size.

Results
Of 68 randomised controlled trials, 10 presented effect sizes for different age groups. The median average cut-off between younger and older age groups was 66 years (IQR 65 to 72.5 years) and the highest cut-off used was 75 years. The median hazard ratio was 0.77 (IQR 0.67 to 0.80) for the younger age group and 0.76 (IQR 0.73 to 0.88) for the older age group. In 8 of the 10 trials, the effect size in the oldest age group was statistically significant on its own including Sacubitril-Valsartan and Dapagliflozin.

Conclusion
When considering the medical therapeutic armamentarium for heart failure as a totality, there is no evidence it is any less effective in older adults than younger adults. The recent Zannad et al cross-trial analysis supported this showing significant additional life years in the patients over 80 years on HF therapy. Whilst there may be practical and frailty-related reasons for not prescribing life-prolonging therapy, the proportional survival benefits of these medications is similar in older adults. This should be utilised where practically possible and discussed with patients when making an informed choice.
98 Rationality of Hypnosedative Use in Seniors in Acute Care: Outputs of the Inomed and Euroageism Projects
Authors: Antonenko O , Zelinková A , Halačová M , Grešáková S , Brkic J , Fialová D 
Published: March 2021

Abstract

Introduction
Insomnia is a frequent problem in acutely hospitalized older adults, particularly in those suffering from polymorbidity and treated by polypharmacy. The aim of our study was to describe the prevalence of insomna and patterns of inappropriately prescribed hypnosedatives in acutely hospitalized older patients in the Czech Republic.

Methods
438 patients (≥65 yrs) acutely hospitalized at 3 geriatric clinics (Brno, Hradec Králové, Praha) in the Czech Republic underwent a comprehensive geriatric assessment (CGA) using the EUROAGEISM H2020 assessment protocols. Descriptive statistics was used to determine the prevalence of insomnia and use of hypnosedatives. Explicit criteria of potentially inappropriate medications (PIMs), mainly 2019 Beers criteria and 2015 EU(7)-PIM list were applied to determine inappropriate patterns of hypnosedatives use.

Results
16.9% (N = 74) seniors had diagnosed insomnia in their medical records, but 34,6% used hypnosedatives in the evening or at night (e/n). 13.8% reported e/n use of drugs aggravating insomnias (particularly beta-blockers- 6.4%, diuretics-2.5% and theophylline- 2.1%). Most frequent hypnosedatives used were: antipsychotics e/n (18.5%), Z-drugs (16,2%) and benzodiazepines e/n (BZD, 14,2%). Non-geriatric doses were determined in users of Z-drugs (10.5%) and sedative antidepressants e/n (1,8%), longer than recommended geriatric duration of therapy has been described for Z-drugs (5.9%,&gt;1 month), BZDs e/n (5,3%,&gt;1 month) and sedative antidepressants e/n (3,3%, &gt;6 months). In total, 1PIM was prescribed to 7.5% of seniors (N = 33), 2PIMs to 2.5% and 3PIMs to 1,1% of seniors. Combination of hypnotics and other sedative drugs was documented in 5.9% of cases.

Conclusion
Inappropriate patterns of hypnosedative use in acutely hospitalized seniors in the Czech Republic at geriatric clinics were found particularly in excessive indication of antipsychotics e/n, inappropriate dosing of Z-drugs and long-term use of BZDs e/n. Supported by: InoMed project (reg. No: CZ.02.1.01/0.0/0.0/18_069/0010046, 2019–2022), EUROAGEISM H2020-MCSF-ITN-764632 project, PROGRESS Q42 Faculty of Pharmacy, Charles University, SVV 260417.
102 Online Supportive Conversations & Reflection Sessions [OSCARS] with Care Home Staff Following A Resident’s Death: Improving Coping Mechanisms, Team Cohesion and Communication
Authors: Hockley J , Johnston L , Watson J , Shenkin S D 
Published: March 2021

Abstract

Introduction
COVID-19 Trauma Guidance suggests opportunities for structured, time-limited discussions about challenging experiences should be offered. It is unknown if such discussions can be effectively delivered online by palliative care specialists to support care home (CH) staff in relation to death/dying. Funded by Scotland’s Chief Scientist Office COVID-19 “rapid research” fund, online OSCaRS is being piloted.

Methods
Fortnightly OSCaRS delivered to small groups of CH staff via a secure online platform in three local CHs over 10 weeks. Sessions are digitally recorded. The shortened version of the Chesney coping self-efficacy questionnaire is completed by all staff pre/post. Additional post-study questions asked of OSCaRS participants and in-depth staff interviews will be undertaken (n = 10). Thematic analysis of the recorded sessions and interviews will be undertaken and related to the staff questionnaire and context of each CH.

Results
New learning on the feasibility and acceptability of providing OSCaRS to frontline staff. The benefit of OSCaRS to CH staff coping mechanisms, team cohesion and communicaton with relatives during the COVID-19 pandemic will be presented. Initial results show that OSCaRS are feasible, valued by all care home staff and support staff in coping with the challenges of COVID-19/.

Key Conclusions
The analysis will inform future practice, and an Implementation Guide for OSCaRS in CHs will be produced. Key learning on the potential for online support in relation to death/dying during the pandemic and beyond will contribute to future education, training and staff wellbeing resources. It will also inform the role of such sessions in developing individual coping mechanisms and team working alongside communication with relatives during lockdown.
104 Assessing for Delirium in A District General Emergency Department—Why are We Failing and How can We Improve?
Authors: Pickard J , Morris R , Crawford I , Mansi R 
Published: March 2021

Abstract

Introduction
Delirium is among the most common of medical emergencies with a prevalence of 20% in adult acute general medical patients. Despite this delirium is underdiagnosed and treatment is variable. Assessment of delirium is missed or carried out unreliably in EDs.

Methodology
Using the Model for Improvement, we developed a driver diagram to plan our project. Assessing whether patients over 65 years old were assessed for delirium during their visit to the ED using a validated tool over a 6-month period. Evaluating the impact of our interventions using annotated run charts. Exclusion criteria—GCS under 13, NEWS2 greater than 5.

Aim
Identify current performance of delirium assessment in over 65 s in Weston General Hospital ED and improve to 100% of over 65 s screened. Assess whether this has been communicated in the discharge summary.

Results
Baseline data showed 22.2% (4/18) of patients meeting inclusion criteria were screened for delirium. We implemented multiple interventions over a 2-month period—discussing at ED handover, hospital wide email, presentation at grand round and displaying a poster in the ED. In the 6 weeks after the interventions were implemented there was increase to 45.4% (15/33) of patients over 65 screened. Delirium/cognitive impairment identified in 42.5% (48/113) of patients screened. This is higher than the national average of hospital admissions therefore it is likely people screen those who display signs of delirium. Cognitive impairment communicated in discharge letter in only 29.4% (33/113) of all patients.

Conclusion
There has been a great improvement in delirium screening. However, we did not meet our target of 100% of patients being screened. Interventions currently being implemented—addition of SQID tool to minors clerking document, addition of compulsory tick box delirium question on all discharge summaries. Further data will be collected to assess effectiveness of these interventions.