bluuebunny/crossref_metadata_2025_split huggingface dataset:
29 Predicting Unplanned Readmission and Death After Hospital Discharge: How Do Frailty Tools Compare to Electronic Health Record Frailty Markers?
Authors: Anand A , Tew Y Yong , Chan J Hao , Keeling P , Shenkin S D , MacLullich A , Mills N , Denvir M A 
Published: March 2021

Abstract

Introduction
Numerous frailty tools and definitions have been described. Amongst hospitalised patients, the validity of face-to-face instruments may be confounded by acute illness. However, patient assessment after recovery at the point of hospital discharge, or recognition of electronic health record (EHR) frailty markers, may overcome this issuep.

Methods
In a consented, prospective observational cohort study, we recruited patients ≥70 years old within 24 hours of expected discharge from the cardiology ward of the Royal Infirmary of Edinburgh. Three established frailty instruments were tested: the Fried phenotype, Short Physical Performance Battery and nurse-administered Clinical Frailty Scale (CFS). An unweighted 32-item EHR score was generated using frailty markers (e.g. falls risk, continence, cognition) recorded within mandated admission documentation. Comorbidity was assessed by count of chronic health conditions. Outcomes were a 90-day composite of unplanned readmission or death and 12-month mortality. Adjusted Cox modelling determined the hazard ratio (HR) per standard deviation increase in each frailty score.

Results
186 patients (mean age 79 ± 6 years, 64% male) were included, of whom 55 (30%) had a 90-day composite outcome, and 21 (11%) died within 12 months. All four frailty tools were moderately correlated with age and comorbidity (Pearson’s r 0.21 to 0.43, all p &lt; 0.05). The Fried phenotype (HR 1.47, 95% CI 1.18–1.81), CFS (HR 1.24, 95% CI 1.01–1.51) and EHR score (HR 1.26, 95% CI 1.03–1.55) independently predicted 90-day readmission or death, after adjustment for age, sex and comorbidity. All frailty instruments were independent predictors of 12-month mortality, with age, sex and comorbidity losing predictive power (p &gt; 0.05) once frailty was included in modelling.

Conclusions
At hospital discharge, the Fried phenotype and CFS added to age and comorbidity in risk prediction for future unplanned readmission or death. EHR frailty markers appeared comparable to face-to-face assessment. An automated trigger for high-risk patients using routine EHR data merits prospective evaluation.
33 Diagnostic Test Accuracy of the 4AT for Delirium Detection: Systematic Review and Meta-Analysis
Authors: Tieges Z , MacLullich A M J , Anand A , Cassaroni M , O'Connor M , Ryan D , Saller T , Arora R , Chang Y , Agarwal K , Taffet G , Quinn T , Shenkin S , Galvin R 
Published: March 2021

Abstract

Introduction
Detection of delirium in hospitalised older adults is recommended in national and international guidelines. The 4 ‘A’s Test (4AT; www.the4AT.com) is a short (&lt;2 min) instrument for delirium detection that is used internationally as a standard tool in clinical practice. We performed a systematic review and meta-analysis of diagnostic test accuracy of the 4AT for delirium detection.

Methods
We searched the following electronic databases through Ovid: MEDLINE, Embase, and PsycINFO. Additional databases were searched: CINAHL (EBSCOhost), clinicaltrials.gov and Cochrane Central Register of Controlled Trials from 2011 (4AT publication) until 21 December 2019. Inclusion criteria: older adults (≥65) across any setting of care except critical care; validation study of the 4AT against a delirium reference standard (standard diagnostic criteria or validated tool). Two reviewers independently screened abstracts and papers and performed the data extraction. Pooled estimates of sensitivity and specificity were generated from a bivariate random effects model.

Results
17 studies (n = 3,701 observations) were included. Various settings including acute medicine, surgery, stroke wards and the emergency department were represented. The overall prevalence of delirium was 24.2% (95% CI 17.8–32.1%; range 10.5–61.9%). The pooled sensitivity was 0.88 (95% CI 0.80–0.93) and the pooled specificity was 0.88 (95% CI 0.82–0.92). The methodological quality of studies was mostly good.

Conclusions
The 4AT is now supported by a substantial evidence base comparable to other well-studied tools such as the Confusion Assessment Method (CAM). The strong pooled sensitivity and specificity findings for the 4AT in this meta-analysis along with its brevity and lack of need for specific training provide support for its use as an effective assessment tool for delirium.
35 Social Contact Mode and 15-Year Episodic Memory Trajectories in Older Adults with and Without Hearing Loss: the Elsa Study
Authors: Rafnsson S , Maharani A , Tampubolon G 
Published: March 2021

Abstract

Introduction
Frequent social contact benefits cognition in later life although evidence is lacking on the potential importance of the modes chosen by older adults for interacting with others in their social network.

Method
11,513 participants in the English Longitudinal Study of Ageing (ELSA) provided baseline information on hearing status and social contact mode and frequency of use. Multilevel growth curve models compared episodic memory (immediate and delayed recall) at baseline and long-term in participants who interacted frequently (offline only or offline and online combined), compared to infrequently, with others in their social network.

Results
Frequent offline (β = 0.29; p &lt; 0.05) and combined offline and online (β = 0.76; p &lt; 0.001) social interactions predicted better episodic memory after adjustment for multiple confounding factors. We observed positive long-term influences of combined offline and online interactions on memory in participants without hearing loss (β = 0.48, p = 0.001) but not of strictly offline interactions (β = 0.00, p = 0.970). In those with impaired hearing, long-term memory was positively influenced by both modes of engagement (offline only: β = 0.93, p &lt; 0.001; combined online and offline: β = 1.47, p &lt; 0.001). Sensitivity analyses confirmed the robustness of these findings.

Conclusion
Supplementing conventional social interactions with online communication modes may help older adults, especially those living with hearing loss, sustain, and benefit cognitively from, personal relationships.
41 A New Ambulatory Frailty Pathway at Barnsley Hospital
Authors: Rycroft W , Madi B 
Published: March 2021

Abstract

Topic
At Barnsley Hospital we targeted an improvement in the care of frail patients. The first objective was to improve the patient journey by reducing the amount of time that frail patients spend in busy acute environments. The second objective was to deliver more effective Comprehensive Geriatric Assessment which is recognised as gold standard management (Ellis, G. BMJ 2011;343:d6553).

Intervention
A new frailty chaired area was opened in July 2018 with capacity to receive up to 6 patients per day from acute admission areas and aim for same day discharge.
We developed our own bespoke criteria to ensure that suitable ambulatory patients were identified to access this new pathway. This was called “FACT” Criteria- Frail, Ambulatory, Clinically stable, Time to call. Patients received an MDT model of care which was documented using a newly developed electronic tool called electronic Comprehensive Geriatric Assessment (eCGA).

Improvement
To evaluate the patient journey we measured the average time between the Acute Medical Unit (AMU) Post Take Ward Round (PTWR) and onward move. Comparison was made between the 2 month periods July—August and November—December 2018. This demonstrated that the average time reduced from 10.3 to 5.1 hours.
Between July 2018 and April 2019 a total of 689 patients were assessed in the frailty chaired area of which 60.8% were discharged from the hospital the same day.

Discussion
The patient journey for frail ambulatory patients now involves significantly less time on AMU awaiting onward move. Comprehensive Geriatric Assessment is delivered more effectively and documented electronically using eCGA. This tool promotes better information sharing and has a specific section for advance care planning.
This new pathway has a high same day discharge rate of 60.8% which reduces length of stay for our frail patients.
45 Quality Improvement Project on Delirium Care in Older Patients at Mid Yorkshire Hospitals NHS Trust (MYHT)
Authors: Mon H , Holt R 
Published: March 2021

Abstract

Background
To improve delirium care in older patients admitted to a large district general NHS Trust in the UK, a quality improvement project was conducted.

Introduction
The national NICE guidelines (CG103) and recent SIGN guidelines recommend delirium is diagnosed by a clinical assessment based on DSM criteria (e.g. CAM or 4AT) and managed by identifying and treating the causes alongside multicomponent interventions.
The results of MYHT’s 2018 delirium audit showed the use of CAM or 4AT was 32.5% and delirium care plan was 20%. A quality improvement project was developed and implemented for 6 weeks on a frailty admission unit.

Method
The quality improvement project introduced a delirium care checklist sticker for medical notes in cases of suspected delirium, brief education sessions for ward doctors regarding delirium care and use of the sticker and reminder emails, all implemented by the elderly medicine registrar. The target measures were completion of stickers, 4AT and delirium care plan. Data was collected by the registrar once a week for 6 weeks and entered into a run chart. Feedback was collected from staff on barriers to use.

Results
31 patients with suspected delirium has their notes reviewed. The sticker use gradually reduced from 57% of cases in week 1, to 0% in week 6. The 4ATwas completed in 57%, 50% and 100% of cases in the first 3 weeks, but dropped to 40%, 4.2% and 1.3% in the last 3 weeks. A delirium care plan was initiated in 42% and 37% of cases in the first two weeks but ended at 0% by week 6.
Barriers included a lack of education sessions from week 2 onwards due to registrar on call shifts. Also junior doctor changeover in week 3. Feedback indicated barriers were time taken to complete, and confusion over ownership of completing 4AT and care plan between medical and nursing teams.

Conclusion
Although a delirium care checklist sticker and brief education sessions can improve delirium care, sustained improvement requires ongoing education and addressing barriers to completion.

References
1. National Institute for Health and Care Excellence (2019) Delirium: prevention, diagnosis and management (NICE Guideline CG103). Available at: https://www.nice.org.uk/guidance/cg103 Accessed 21/09/2019].
2. Scottish Intercollegiate Guidelines Network (2019) risk reduction and management of delirium (SIGN Guideline 157). Available at https://www.sign.ac.uk/assets/sign157.pdf. Accessed 21/09/2019.
48 Do Exercise Programmes for Older People with Sarcopenia or Frailty Deliver An Evidence-Based Service? Findings From A UK Survey
Authors: Chawner M , De Biase S , Offord N J , Todd O , Clegg A , Sayer A A , Witham M D 
Published: March 2021

Abstract

Background
Awareness of sarcopenia and frailty is growing and both are known to be potentially reversible with effective resistance training. We aimed to establish whether existing exercise programmes offered to people with sarcopenia or frailty adhere to the known evidence base.

Methods
We conducted a national on-line survey of practitioners delivering exercise programmes to older people with sarcopenia or frailty. The link to the online survey was distributed through the British Geriatrics Society, Chartered Society of Physiotherapy Special Interest Group for Older People (AGILE), the NHS England Future Collaboration Platform “Supporting People Living with Frailty” forum and social media. Questions covered target population and aims of the exercise programme, type, duration and frequency of exercise, progress assessment and outcome measures. Descriptive analyses were conducted using SPSS v24.

Results
136 responses were received from respondents who worked for NHS Trusts, clinical commissioning groups, private practices, and third sector providers. 94% of respondents reported prescribing or delivering exercise programmes to people with sarcopenia or frailty. Most programmes (81/135 [60%]) were primarily designed to prevent or reduce falls. Resistance training was reported as the main focus of the programme in only 11/123 (9%); balance training was the main focus in 61/123 (50%) and functional exercise in 28/123 (23%). Exercise was offered once a week or less by 81/124 (65%) of respondents; the median number of sessions offered was 8.5 (IQR 6 to 12). Outcome measures suitable for assessing the effect of resistance training programmes were reported by fewer than half of respondents (hand grip: 13/119 [11%]; chair stands: 55/119 [46%], short physical performance battery: 4/119 [3%]).

Conclusions
Current exercise programmes offered to older people with sarcopenia or frailty lack the frequency, duration or specificity of exercise likely to improve outcomes for this group of patients.
139 What are the Barriers and Facilitators to Effective Advance Care Planning (ACP) in Residential Care Settings for Older People?
Authors: Chumbley K 
Published: March 2021

Abstract

Introduction
ACP is recommended for all people approaching the end of life but there is an inequality in access to ACP for care home residents. In North East Essex there has been an Electronic Palliative Care Coordination system (EPaCCS) in place for 6 years, currently without care home staff access capability. The aim of this study was to investigate ACP within care homes within this context.

Method
A qualitative study, with semi-structured interviews with fourteen senior care home staff from ten care homes across North East Essex. The interview transcripts underwent thematic analysis regarding facilitators and inhibitors to effective ACP.

Results
Four overarching themes were identified. These were relationships, communication, healthcare systems and attitudes. Care home staff considered ACP to be part of their role but perceived their work in this area to be separate from that performed by other health care professionals. The care home staff awareness of ACP done by other health care professionals was limited. Care home staff were aware of the EPaCCS, but only a minority perceived it to impact on residents care. All interviewees were keen to have access to the EPaCCS. Many of the facilitators and barriers to effective ACP in this locality are consistent with those found in prior literature. Having an EPaCCS within the area did not alleviate a perceived barrier of poor communication. Relationships between staff, residents, families and health care professionals remain the most common facilitators to ACP, with continuity of care from primary care, specialist palliative care and paperwork tools remaining important.

Conclusion
To overcome the inequity of access to ACP for residents in care homes interventions could be commissioned to address current barriers. These could include communication skills training, aligned primary care and community services as well as technological support for communication with family and access to EPaCCS.
143 Barriers and Facilitators of General Practice in the Care Home Setting- A Qualitative Study to Inform Training of GPS
Authors: Ruaux S , Chadborn N 
Published: March 2021

Abstract

Introduction
Care home (CH) residents receive varying quality and availability of healthcare. GPs are tasked with the responsibility of providing effective care to this growing demographic. The study aimed to gain an insight into the experiences of GPs carrying out CH work, in order to produce training recommendations.

Method
Two trainees, one trainer and twelve senior GPs were recruited informally through professional networks. Each completed a semi-structured interview about their work within CHs. Transcriptions were made and then analysed using thematic analysis.

Results
The two trainee participants had different experiences of CH work, but neither had received any specific training. The trainer GP acknowledged that multiple existing trainee competencies were relevant to CHs, but that inconsistencies in CH exposure were present and that specific training would be beneficial. The senior GP participants did not recall having received CH-specific training. Many factors contributed to the delivery of care within the CHs and made it distinct from the work within the GP surgery. Participants reported a variety of approaches to care, these related to different multidisciplinary teams, the involvement of CH staff, and the complex nature of the care of residents. Advance care planning was a beneficial approach used by some of the GPs that required particular attention and skills.

Conclusion
A tension was present between the care GPs wanted to provide and the complexities that inhibited them from doing so. The challenges relate to the need for multidisciplinary care teams to address complex needs of individual residents, and an acknowledgement of the importance of the relationship with the CH staff in supporting continuity of care. Overall, the complex nature of CH work, and the current inconsistencies in trainee’s exposure, justify the need for a new approach to provide all trainee GPs with experience of working within the CH setting.
144 Probable Delirium is A Presenting Symptom of COVID-19 in Frail, Older Adults: A Study of Hospitalised and Community-Based Cohorts
Authors: Penfold R S , Zazzara M B , Roberts A L , Lee K A , Dooley H , Sudre C H , Welch C , Bowyer R C E , Visconti A , Mangino M , Freidin M B , El-Sayed Moustafa J S , Small K , Murray B , Modat M , Wolf J , Ourselin S , Martin F C , Steves C J , Ni Lochlainn M 
Published: March 2021

Abstract

Introduction
COVID-19 exhibits a more severe disease course in older adults with frailty. Awareness of atypical presentations is critical to facilitate early disease identification. This study aimed to assess how frailty affects presenting symptoms of COVID-19 in older adults.

Methods
Observational study of two distinct cohorts: (i) Hospitalised patients aged 65 and over; unscheduled admission to a large London teaching hospital between March 1st, 2020-May 5th, 2020; COVID-19 confirmed by RT-PCR of nasopharyngeal swab (n = 322); (ii) Community-based adults aged 65 and over enrolled in the COVID Symptom Study mobile application between March 24th (application launch)-May 8th, 2020; self-report or report-by-proxy data; reported test-positive for COVID-19 (n = 535). Multivariable logistic regression analysis performed on age-matched samples of both cohorts to determine associations between frailty and symptoms of COVID-19 including delirium, fever and cough.

Results
Hospital cohort: there was a significantly higher prevalence of delirium amongst the frail sample, with no difference in fever or cough. Of those presenting with delirium, 10/53 (18.9%) presented with delirium as the only documented symptom. Community-based cohort: there was a significantly higher prevalence of probable delirium in the frail sample, and also of fatigue and shortness of breath. Of those reporting probable delirium, 28/84 (33%) did not report fever or cough.

Conclusions
This study demonstrates a higher prevalence of delirium as a presenting symptom of COVID-19 infection in older adults with frailty compared to their age-matched non-frail counterparts. Clinicians should suspect COVID-19 in frail older adults presenting with delirium. Early detection facilitates infection control measures to mitigate against catastrophic spread and preventable hospitalisations and deaths amongst this population. Our findings emphasise the need for systematic frailty assessment for all acutely ill older patients in both hospital and community settings, as well as systematic evaluation of any change in mental status.
154 The Feasibility of Assessing Sarcopenia Among Older People with Arm Fracture Using Different Criteria
Authors: Ibrahim K , Mullee M A , Yao G Lily , Zhu S , Baxter M , Tilley S , Russel C , Roberts H C 
Published: March 2021

Abstract

Introduction
Osteoporosis and sarcopenia often co-exist (osteo-sarcopenia) and both are associated with increased risk of falls and fractures. Early identification and treatment of sarcopenia among older people with fragility arm fractures could prevent further fractures. This study evaluated the feasibility of assessing sarcopenia in a fracture clinic.

Methods
People aged 65+ years with arm fracture attending fracture clinics in one acute trust were recruited. Sarcopenia was assessed using gait speed, grip strength with unfractured arm (hand dynamometer using appropriate cut off adjusted for age and gender), skeletal muscle mass index SMI (Bioimpedance BIA), SARC-F questionnaire, the European Working Group on Sarcopenia in Older People (EWGSOP) I and II criteria. The sensitivity and specificity of each measure was calculated against the EWGSOP II criteria as the standard reference.

Results
100 patients (Mean age 75 years±7.2; 80 female) were recruited. Sarcopenia was identified among 4% (EWGSOP I), 5% (SMI), 13% (EWGSOP II), 16% (gait speed test), 18% (SARC-F) and 39% (grip strength) and was more prevalent among men. SARC-F had the best sensitivity and specificity (100% and 96% respectively) when compared to the EWGSOP II criteria. Sensitivity and specificity for the remaining measures were respectively (100%, 71%) for grip strength, (75%, 94%) for gait speed, (25%, 97%) with SMI and (25%, 99%) for EWGSOP I. Time needed to complete the assessments was 1–2 minutes for gait speed, grip strength and SARC-F; five minutes for BIA test, and nine minutes when EWGSOP I and II criteria were applied. Data were complete for grip strength and SARC-F. Missing data was reported among 2% for gait speed, 8% for BIA test, 8% for EWGSOP II and 10% for EWGSOP I.

Conclusion
It was feasible to assess sarcopenia in fracture clinics and SARC-F was a quick, simple and sensitive tool suitable for routine use.
159 Antibiotic Omissions: A Missed Dose Means A Missed Chance to Save A Life! Is E-Prescribing the Answer?
Authors: Manzoor M , Atique A , Chowdhury R , Athavale N 
Published: March 2021

Abstract
Omissions and delay in antimicrobial therapy are common in acute hospitals with an untowrds impact on patient outcomes resulting in harm and prolong stay. We carried out a Quality Improvement Project (QIP) assessing 2 interventions in PDSA cycles to improve situation. This QIP was done in 3 stages and involved about 80 patients over 7 months. We collected data regarding antibiotic omissions on 3 random separate days which gave baseline omission rate. This was 8.5% and quite higher than the national average (5.3%). The reason for the omissions was not documented on the drug kardexes on most occasions. Initial intervention included staff education, verbally and through posters. Post intervention data was collected again on 3 separate days. This showed improvement and the omission rate fell from 8.5% to 5.6%. The percentage of omissions with no code written reduced from 56.25% to 18.18%. The second intervention included participation in EPMA (Electronic prescribing and medicines administration) pilot on the ward. Post EPMA, the omission rate reduced to 4.59%. All omissions had now a code written. The phenomenon of Antibiotic Omissions is an open challenge and its consequences are serious. We can conclude from our study that educational measures though effective are likely to be short-lived.Therefore, it can be asserted that Electronic prescribing is appropriate solution for antibiotic omissions and it also opens up new horizons for patient safety.