bluuebunny/crossref_metadata_2025_split huggingface dataset:
524 QUALITY IMPROVEMENT PROJECT: INCORPORATING COMPREHENSIVE GERIATRIC ASSESSMENT INTO COMMUNITY HOSPITAL CLERKING
Authors: Oates A 
Published: June 2021

Abstract
Elderly patients transferred to community hospitals often have complex medical, social, psychological, functional and pharmacological backgrounds that require careful assessment in order to create and deliver a high quality, patient-centred care plan. Unfortunately, time pressures experienced by staff in acute hospitals can make Comprehensive Geriatric Assessment (CGA) unfeasible for every patient. Moreover, junior members of the medical team may be unsure as to which aspects of a patient’s background and presentation constitute important elements of a CGA. Failure to recognise and document pertinent issues can lead to prolonged admissions, disjointed care and failed discharges.
Admission to a community hospital presents a convenient ‘checkpoint’ in the patient’s hospital journey at which to undertake a CGA. Recording the relevant information in an effective clerking proforma when the patient is admitted ensures that this information is displayed clearly and in a way that is accessible to all members of the multidisciplinary team. The pre-existing clerking proforma at Amersham Community Hospital omitted several important elements of CGA (such as examination of feet and gait, assessment of mood, FRAX-UK score, creation of a problem list etc.) The aim of this quality improvement project was to create a thorough, yet user-friendly and time-efficient clerking proforma which incorporated the important components of CGA.
Using BGS guidance and NICE quality standards, alongside suggestions from the medical team, the existing clerking proforma was adapted and reformed. After one month, feedback from the team was used to further improve the clerking proforma, ensuring that it was user-friendly, whilst meeting the standards set out by NICE and BGS. This was repeated as part of a second PDSA cycle.
The improved clerking proforma enables junior doctors to undertake a thorough and holistic assessment, promoting efficient detection of issues and the delivery of a higher quality of care.
525 EVERYONE NEEDS TO POOP: REDUCING CONSTIPATION IN THE ELDERLY INPATIENT POPULATION
Authors: Rollo-Walker J C R G 
Published: June 2021

Abstract

Introduction
Due to a variety of factors when elderly patients are admitted to hospital they can become constipated. This can impact the entire admission increasing morbidity and mortality for what is a treatable problem. The aim therefore was to assess how prevalent constipation was across the inpatient population; analyse if there were any common themes and implement interventions that might help solve these.

Method
Data was collected over 15 days across the department (up to 87 patients) using nursing handover sheets to review the date bowels had last been opened. Patients were classified as constipated if they had not opened their bowels for more than 3 days. On two days common themes in the constipated patients were reviewed and analysed. On average 27% of patients were constipated. The majority of these had been deemed ‘Medically Ready for Discharge’. They all had either no or only a reduced range of aperients prescribed. Stakeholders including patients, nursing staff, prescribers and Consultants were surveyed. First cycle intervention was to highlight those constipated at morning Multi-disciplinary Team (MDT) meetings to prompt medical review. Second cycle intervention: an e-prescribing bundle was designed to allow for simple prescription and for nurses to give aperients on an as required basis. A laxative prescribing guide sheet was also written to aid prescribers.

Results
Aim is to reduce constipation to less than 20% thereby reducing morbidity and mortality in inpatients. Highlighting patients at MDT had little effect partly as it was person dependent. Effect of prescribing bundle yet to be determined but received positively by stakeholders. Prescribing guide received positively by Consultants and junior prescribers.

Conclusions
Person dependent intervention was ineffective at reducing constipation highlighted by staff sickness due to Covid-19. A prescribing bundle is more system based. If used at admission hopefully will be effective and sustainable.
533 READMISSIONS TO GERIATRIC MEDICINE IN A DISTRICT GENERAL HOSPITAL, A THEMATIC ANALYSIS
Authors: Whiting R , Comerford R 
Published: June 2021

Abstract

Introduction
621 patients were readmitted within 30 days of discharge from our Geriatric Medicine department between October 2019 and March 2020. This project was undertaken to better understand whether some of these readmissions could be prevented.

Methods
Analysis showed a clear peak of 78 patients returning at day one post discharge, and a subsequent Pareto analysis revealed that nearly 80% of these were discharged from 2 locations, our frailty unit and MAU. This cohort became the focus of our review. With support from the Acute Frailty Network, a virtual structured case note review was undertaken by a multidisciplinary team including an independent Geriatrician. This considered the patient’s case, whether they were cared for by the right team in the right place, whether they were readmitted with a new diagnosis and whether any improvements in the discharge process or wider service could have prevented their readmission.

Results
The case note review process was halted early as clear recurring themes emerged. Firstly, feedback showed that all frail patients were identified early in the patient pathway, were cared for by the appropriate team and a CGA was commenced promptly. Secondly, whilst the majority of day one readmissions had a diagnosis of delirium, most were not diagnosed as such until their re-attendance, despite documented confusion. Failure to recognise this, treat their delirium, and plan for fluctuations in cognition upon discharge were found to contribute to a high readmission rate.

Conclusion
We found that delirium identification was a key factor in early readmissions to our service. We identified clear opportunities to strengthen and formalise delirium diagnoses, and better plan patient management and discharge plans as a result. A multidisciplinary quality improvement group looking at delirium has been initiated and has already achieved a statistically significant improvement in the use of 4AT, a delirium assessment tool.
573 DELIRIUM SCREENING QUALITY IMPROVEMENT PROJECT
Authors: Al-Alousi S , Khan A U , Laithwaite E 
Published: June 2021

Abstract

Introduction
Delirium is a common neuropsychiatric syndrome in patients over the age of 65 presenting to medical admissions units yet remains under-diagnosed despite significant associated mortality and morbidity. Our trust's delirium screening tool incorporates a four-step approach, with completion of validated 4AT test warranted in all those over 65 years of age admitted with increased confusion or social withdrawal. Our aim was to measure current uptake of this delirium screening and introduce measures to improve practice.

Method
We retrospectively collected data from medical records of patients on two Geriatric inpatient wards (42 patients) at the Leicester Royal Infirmary, to determine whether appropriate delirium screening was taking place for at-risk patients on admission. We then introduced two PDSA (plan, do, study, act) cycles: 1. teaching at departmental weekly educational meetings with sending electronic communications to all doctors in medicine highlighting importance of delirium screening; and 2. displaying posters on all admissions wards. A third cycle was planned involving visiting wards to raise awareness, however this was interrupted by the COVID pandemic.

Results
Initial baseline results showed only 5% (1 of 18) of at-risk patients were fully screened for delirium. Following our first intervention, this increased to 13% (3 of 23). Second intervention involving display of posters led to an increase to 44% (8 of 18) of at-risk patients being screened. Proportions of dementia were comparable across PDSA cycles.

Conclusions
Education, raising awareness, and display of reminder posters can improve delirium screening uptake of at-risk patients on admission to medical admission units, despite growing pressures associated with the COVID pandemic. Further interventions are planned to improve and maintain awareness and uptake of delirium screening.
601 IMPROVING DELIRIUM ASSESSMENT IN A DISTRICT GENERAL HOSPITAL
Authors: Finlow C , Azaden L , Abbott C 
Published: June 2021

Abstract

Introduction
Delirium affects a up to 20% of medical inpatients1. Patients in the high-risk category include those over 65, pre-existing cognitive impairment, current hip fracture and those with a serious illness 1,2.
Often delirium goes undetected but is often related to high morbidity and motility rates with complications of insitionalisation, increased risk of dementia, high risk of falls and prolonged hospital stays1,2, recognition is the first step to reducing these risks. NICE guidance suggests that those patients showing indicators of delirium should have a formal cognitive assessment and a tailor-made plan should be documented within 24 hours 2.
The detection of delirium can be sort using licensed tools including the 4AT score with the 4AT being the most sensitive, specific and practical1. Due to the ongoing risks of delirium, high risk patients on the Geriatric medicine firm and poor detection rate a quality improvement methodology was used to increase the rates of detection of delirium.
The aim to have 90% of Geriatric medicine patients screened within 24 h admission and within 24 h of arrival to COTE ward/first consultant ward round within 4 months.

Method
4 PDSA cycles were designed to trial changes including education of the Geriatric medicine team, lanyard cards, introduction of 4AT on the frailty proforma and a non-intervention cycle to see if these changes were sustained.
Data was collected from the care of the elderly ward not including outliers of 27 patients. Any formal cognitive assessment that was documented either on admission or on arrival to the ward was included. Not included was those patients who were assessed for delirium or change in cognition after first consultant ward round or after 24 h of being on the ward.

Results
The uptake of 4AT improved by 50% after education and the lanyard cards. This was largely as a shift away from other assessments rather than more cognitive assessments done overall.
During service redesign an Older Person’s Assessment Unit was formed with a Geriatrician based at the front door. This will improve the use of the 4AT for older patients admitted to hospital in the near future and is the subject of the next PDSA cycle.

Conclusion
Our journey to embed the 4AT is ongoing and we will continue to improve uptake using QI methodology.
535 ELF 2: DEFINING THE DENOMINATOR ELF STUDY GROUP
Authors: Price A , Mclennan E , Boyle J ,   on behalf of the ELF2 study group
Published: June 2021

Abstract

Introduction
The collaborative UK Emergency Laparotomy and Frailty (ELF) study was one of the first to investigate the older adult population undergoing emergency surgery. Despite accounting for almost half of emergency laparotomies and many considered high-risk, there remains a paucity of research in this population. One undefined area is the older patient who presents with acute abdominal pathology treatable by laparotomy but who do not undergo surgery.

Aims
The primary aim is to estimate the 90-day mortality in older patients presenting with acute abdominal pathology potentially treatable by emergency laparotomy who do not undergo surgery (NoLap). The secondary aims are characterisation of this group, including frailty and sarcopenia with comparison to those older adults that have undergone emergency laparotomy (NELA and ELLSA). In addition, the decision-making process will be explored.

Method
Multicentre prospective cohort study via established research collaboratives (Welsh Barbers, SSRG, OPSOC). ELF 2 requires at least 47 centres, recruiting 700 patients for 3 months prospective data collection via REDCap of NoLap patients with the same NELA inclusion/exclusion criteria. This data will be compared with a matched cohort from NELA and ELLSA. ELF2 data collection includes demographics, co-morbidities, frailty and sarcopenia. Each patient will be followed up for 90-day and 1-year mortality. Heuristics behind the decision will be analysed.

Discussion
This trainee led collaborative project aims to improve understanding of the older adult population being considered for emergency laparotomy. With the ageing population being the dominant health users of the future, defining the denominator is essential for shared decision-making.
434 LOOK OUT! VISUAL ASSESSMENT TOOL: UTILITY IN OLDER PERSON’S MENTAL HEALTH CARE SETTINGS
Authors: Hussain S , Thavachelvi C , Ruiz-Mendoza E 
Published: June 2021

Abstract

Introduction
Patients on old age psychiatry wards are at high risk of falls. It has been shown that poor visual acuity significantly increases the risk of recurrent falls in the elderly. The National Audit of Inpatient Falls (NAIF) Report 2015 found that vision was poorly assessed. The Look Out! Visual assessment has been developed for patients over 65 to receive visual screening on admission to reduce the risk of falls. To date, there has been no research into the applicability of the Look Out! test in mental health settings. Our aims are two-fold: (i) To investigate how often vision is assessed for inpatients on old age psychiatry wards and (ii) To identify the challenges of visual assessment in a mental health care setting.

Methodology
Data was collected at a mental health unit with two wards dedicated to old age psychiatry patients. Data was collected for patients admitted from May 2020 to July 2020 and analysing qualitative and quantitative data.

Results
From the 30 patients reviewed, 27% of patients had ophthalmic history, such as glaucoma or cataracts, 23% of patients had a fall during admission, yet only 43% of patients had a Look Out! vision assessment completed and documented. 54% of patients who had a Look Out! Assessment were found to have an abnormality; of those with an abnormality detected on Look Out!, 57% were new presentations of an eye abnormality. On questionnaires, we found it more challenging to complete assessments of patients that were agitated or with advanced dementia but assessments were fully completed if more time was dedicated.

Conclusions
These findings demonstrate that the Look Out! test is applicable in mental health settings, helping to identify those with visual impairments and raising the need to complete the screening tool in all patients admitted to inpatient mental health facilities.
407 QUALITATIVE ASSESSMENT OF COGNITIVE TRAINING FOR PEOPLE LIVING WITH DEMENTIA: AN INDIVIDUALISED APPROACH IS NEEDED AUTHORS
Authors: Beishon L , Haunton V , Subramaniam H , Mukaetova-Ladinska E , Paneraia R , Robinson T , Evley R 
Published: June 2021

Abstract

Background
Cognitive training (CT) may be beneficial in mild cognitive impairment (MCI) and early dementia. However, few studies have qualitatively evaluated CT programmes in dementia. The aim of this analysis was to explore the benefits and barriers to a home-based computerised CT programme for healthy older adults, and people living with MCI or dementia.

Methods
This was a nested qualitative study within a larger feasibility randomised trial of CT. Participants underwent semi-structured interviews after 12 weeks of CT. Where possible, participants were interviewed with their carers. The interview schedule and analysis were underpinned by the health belief model. Interviews were audio-recorded, transcribed, open-coded, and categorised into themes. The analytical framework was developed, and themes were condensed under four major categories: benefits and efficacy, barriers, threat, and behaviour.

Results
37 participants underwent interviews (10 healthy older adults, 4 MCI, 5 dementia, 9 patient-carer dyads [2 MCI, 7 dementia]). CT was feasible and acceptable to participants. Benefits included: enjoyment, improved awareness, benchmarking cognitive function, reassurance of abilities, and giving back control. Barriers were more prevalent amongst those with dementia: problems with technology, frustration, conflict between patients and carers, apathy and lack of insight, anxiety or low mood, and lack of portability. Perceived risk susceptibility of dementia varied between participants. Healthy older adults and MCI perceived the severity of dementia risk as high, which was only partially mitigated by CT. Participants living with dementia valued a more individualised approach to training, accounting for baseline characteristics. For people living with dementia, maintenance was as valued as improvement of cognitive function.

Conclusions
CT was a feasible intervention for healthy older adults, and people living with dementia and MCI. Benefits were present, but the identified barriers need to be addressed for CT to be implemented successfully.
494 DISCOMFORT IN PEOPLE WITH DEMENTIA ADMITTED TO AN ACUTE GENERAL MEDICAL HOSPITAL: A HOSPITAL CROSS SECTIONAL STUDY OF PREVALENCE
Authors: Low R , West E , Sampson P L 
Published: June 2021

Abstract

Introduction
The acute hospital is a challenging place for a person with dementia whose ability to communicate discomfort and need is impaired. Their discomfort may go unnoticed due to insufficient staffing and time resources in this acute environment. Concerns have been raised about the consequences of these overlooked discomfort (e.g. distress and agitation), and hence how we can correctly identify their sources and severity. This study aimed to describe the source of discomfort and challenging behaviours in people with dementia (PwD) in UK acute hospital.

Method
A cross-sectional observational study of 49 patients with dementia admitted to a NHS acute hospital. Their discomfort was detected and its sources were identified (Sources of Discomfort Scale) during an hour observation when they were at rest and moved by staff. Their challenging behaviours were also recorded (Neuropsychiatric Inventory) through interviewing with the ward staff, as well as documentation of severity of dementia and presence of delirium.

Results
The overall prevalence of discomfort was 98%, with excessively sleepy or tired being the commonest; 39 (80%) participants experienced three or more type of discomfort. The commonest sources of discomfort were physical (e.g. constipation) and environmental (e.g. physically restrained), affecting up to 43 (88%) and 42 (83%) participants respectively. There was also evidence of an association between delirium and sleepiness or tiredness’s discomfort, meaning that PwD with delirium were nearly triply as likely to feel uncomfortable because of sleepiness or tiredness. Challenging behaviours affected over 80% of our participants, with agitation or aggression being the commonest. On average, these behaviours were moderately severe.

Conclusion
Discomfort and challenging behaviours were very common in PwD admitted to acute hospitals. Patients and staff would benefit from more accurate and frequent detection of discomfort by focusing on non-pain-related discomfort and using observational scales.
505 INTERLEUKIN-6, C-REACTIVE PROTEIN, FIBRINOGEN, AND RISK OF RECURRENCE AFTER ISCHEMIC STROKE: SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: McCabe J J , O’Reilly E , Coveney S , Harbison J , Collins R , Healy L , McManus J , Mulcahy R , Moynihan B , Cassidy T , Hsu F , Worrall B , Murphy S , O’Donnell M , Kelly P J 
Published: June 2021

Abstract

Background
Recent randomised trials showed benefit for anti-inflammatory therapies in coronary disease but excluded stroke. The prognostic value of blood inflammatory markers after stroke is uncertain and guidelines do not recommend their routine measurement for risk stratification.

Methods
We performed a systematic review and meta-analysis of studies investigating the association of C-reactive protein (CRP), interleukin-6 (IL-6) and fibrinogen and risk of recurrent stroke or major vascular events (MVEs). We searched EMBASE and Ovid Medline until 10/1/19. Random-effects meta-analysis was performed for studies reporting comparable effect measures.

Results
Of 2,515 reports identified, 39 met eligibility criteria (IL-6, n = 10; CRP, n = 33; fibrinogen, n = 16). An association with recurrent stroke was reported in 12/26 studies (CRP), 2/11 (fibrinogen) and 3/6 (IL-6). On random-effects meta-analysis of comparable studies, CRP was associated with an increased risk of recurrent stroke [pooled hazard ratio (HR) per 1 standard-deviation (SD) increase in loge-CRP (1.14, 95% CI 1.06-1.22, p &lt; 0.01)] and MVEs (pooled HR 1.21, CI 1.10-1.34, p &lt; 0.01). Fibrinogen was also associated with recurrent stroke (HR 1.26, CI 1.07-1.47, p &lt; 0.01) and MVEs (HR 1.31, 95% CI 1.15-1.49, p &lt; 0.01). Trends were identified for IL-6 for recurrent stroke (HR per 1-SD increase 1.17, CI 0.97-1.41, p = 0.10) and MVEs (HR 1.22, CI 0.96-1.55, p = 0.10).

Conclusion
Despite evidence suggesting an association between inflammatory markers and post-stroke vascular recurrence, substantial methodological heterogeneity was apparent between studies. Individual-patient pooled analysis and standardisation of methods are needed to determine the prognostic role of blood inflammatory markers and to improve patient selection for randomised trials of inflammatory therapies.
530 INTERPRETATION OF HBA1C VALUES IN GERIATRIC PATIENTS WITH TYPE 2 DIABETES: LARGE DIVERGENCE BETWEEN CLINICAL PRACTICE GUIDELINES
Authors: Christiaens A , Boland B , Henrard S 
Published: June 2021

Abstract

Introduction
An individualised glycated haemoglobin (HbA1c) target according to the patients’ health status is central in the glycaemic management of geriatric people with type 2 diabetes (T2D) in order to avoid hypoglycaemic events through an appropriate management of the glucose-lowering therapy (GLT). Current clinical practice guidelines (CPGs) provide different recommendations for patients’ HbA1c targets. Using real-life data from geriatric patients, this study aimed at assessing the concordance in interpretation of HbA1c values according to three current major CPGs from the Diabetes Canada-2018 (DC18), the Endocrine Society-2019 (ES19) and the American Diabetes Association-2020 (ADA20).

Introduction
Retrospective study in consecutive older patients (≥75 years) with T2D admitted to a Belgian geriatric ward, with GLT before admission and HbA1c measurement during the hospital stay. Patients were classified into three categories of HbA1c values according to the CPGs recommendations: in-target HbA1c (appropriate-GLT), too-low HbA1c (GLT-overtreatment) and too-high HbA1c (GLT-undertreatment). Concordance of health status classifications and GLT categories between the three CPGs was assessed using Cohen’s and Fleiss’ κ, respectively.

Results
Of the 318 patients (median age 84 years, 54% women), one-third were in intermediate health and two-thirds in poor health (κ = 0.86; excellent concordance). According to the DC18, ES19 and ADA20 CPGs, HbA1c was in-target for respectively 46%, 25% and 82% of the patients, and too-low HbA1c (GLT-overtreatment) was present in 28%, 57% and 0% (κ = 0.36; low concordance).

Results
Patients’ HbA1c values are interpreted differently according to these major CPGs, mainly because of differences in their recommendations about HbA1c target individualisation and specifically the definition of a too-low HbA1c value. In clinical practice, these diverging interpretations regarding overtreatment may lead to unsafe GLT prescribing and thereby to hypoglycaemic events in this high-risk population.