bluuebunny/crossref_metadata_2025_split huggingface dataset:
148 Lipid Targeting Post-Stroke—Targeting Who?
Authors: Micallef C , Bingham K , Barber J M 
Published: March 2021

Abstract

Introduction
Frailer patients are at high risk of complications from drugs like statins. Other less frail patients may be undertreated. The Treat Stroke to Target trial showed that high risk patients with atherosclerosis and/or ischaemic heart disease (IHD) who were treated to an LDL level of less than 1.8 mmol/L had a 22% relative risk reduction in major cardiovascular events compared to those with a higher target. In our Quality Improvement.

Project
We estimated the numbers of post-stroke cases who might safely benefit from a targeted, pharmacist led intensive lipid management program.

Methods
500 consecutive ischaemic stroke cases with a modified Rankin score (mRS) of 0–3 were identified from the Scottish Stroke Care Audit Database. Those discharged to long term care or dead at the time of data collection were excluded. Data collected was age, evidence of atherosclerosis on vascular imaging, co-morbid IHD, LDL at index admission and between 1 month to 1 year post-stroke, anti-lipid treatment at discharge and up to 1 year post-stroke. Atrial fibrillation patients were included if other risk criteria were met.

Results
The mean age of the 500 cases was 70. From this group, 297 (60%) met the entry criteria for “Treat to Stroke Target”. 190 (64%) cases had LDL checked post-discharge. 87 cases failed to reach the RCP Stroke Guidance of a 40% reduction in LDL Cholesterol. 66 (22%) of cases had LDL &gt;1.8 mmol/L on most recent check and potentially should have been treated to target. Of the 83 cases excluded due to mRS &gt;3 or significant dependency, 70 cases (84%) were discharged on a statin and importantly 34 (48%) of these died within 1 year of their stroke.

Conclusions
Based on annual stroke admissions in our health board, around 86–117 high risk patients could benefit from a virtual lipid treatment intensification clinic.
161 Does the Weather Contribute to Admissions of Neck of Femur Fractures?
Authors: Koizia L J , Dani M , Brown H , Lee M , Fertleman M B 
Published: March 2021

Abstract

Introduction
The effects of weather on overall mortality are well documented. Anecdotally, icy conditions are perceived to result in more falls and admissions for neck of femur (NOF) fractures. The aim of this unfunded pilot study was to determine whether relationships could be extracted or at least not ruled out by analysing a small dataset, and so give impetus to a larger project.

Methods
Seven trauma units across north west London were identified and NOF fracture data extracted for five years. Visual inspection of the time series, consideration of the weather on specific days and correlation analysis were used to assess causal links between fracture numbers and a variety of weather parameters (temperature, rainfall, wind and ice risk).

Results
Overall, 10,929 individuals with hip fractures were admitted over the five-year period. The highest number of admissions in a day was 14. No clear association was found between a weather parameter and daily admissions. However, when accumulated to a weekly timescale, a negative relationship with maximum temperature was found. No seasonal cycle was detected.

Conclusion
The lack of a daily relationship and presence of a weekly relationship points to a possible delayed response to weather or insufficient daily data to extract a signal. The inconclusive results also indicate that more socioeconomic data will need to be used in future studies, requiring a larger data sample. In addition, even in cold weather an urban environment may not create icy conditions, being ameliorated by the heat island effect and gritting.
52 I’m on the Floor and Can’t Get up and it’s Really Annoying: A Qualitative Investigation of Patient and Staff Perceptions of Options for Getting up From the Floor Following A Fall
Authors: Swancutt D , Hope S V , Kent B , Robinson M , Goodwin V 
Published: March 2021

Abstract

Background
Falls are the most common reason for ambulance call-outs resulting in non-conveyance. Even in the absence of injury, only half of those who have fallen can get themselves up off the floor. Many remain there for over an hour, increasing complications risks.
It is feasible to teach people techniques to help get themselves off the floor, yet these techniques are rarely taught. To date, there are no published data on attitudes towards teaching and learning these techniques. Our study aimed to investigate patient, carer and staff attitudes towards seeking help and using techniques to get-up following a fall.

Methods
A qualitative focus group and semi-structured interviews were conducted with 28 participants, including community-dwelling older people who had experienced a non-injurious fall, carers, physiotherapists, occupational therapists, paramedics and community first responders.
Data were transcribed and analysed systematically using the Framework approach. A stakeholder group of falls experts and patients advised during analysis.

Results
The data highlighted three areas contributing to an individual’s capability to get-up following a fall: the environment (physical and social); physical ability; and degree of self-efficacy (attitude and beliefs about their own ability). These factors influenced each person’s capability to manage their fall response.
Staff described how they balance their responsibilities, prioritising the individual’s immediate needs; this leaves limited time to address capability in the aforementioned three areas. Paramedics, routinely responding to falls, only receive training on getting-up techniques from within their peer-group. Therapists are aware of the skillset to breakdown the getting-up process, but, with limited time, select who to teach these techniques to.

Conclusion
Neither therapists nor ambulance service staff routinely teach all those at risk of falling strategies on how to get-up. Interventions to positively impact on capability to get-up following a fall should include strategies that address the environment, physical ability and self-efficacy.
59 Improving the Identification and Management of Delirium in Older Surgical Patients
Authors: Baguneid C L , Millington K L , Pattinson J , Ogden G , Malcolm F , Gordon A L 
Published: March 2021

Abstract

Local Problem
A multidisciplinary team comprising a consultant geriatrician and nurse consultant reviews all patients aged ≥70 years who have an emergency laparotomy at Royal Derby Hospital. Anecdotally there is a high incidence of delirium but retrospective casenote audit found only 19% of patients admitted for emergency laparotomy July 2018–July 2019 were identified as having delirium by the surgical team.

Method
A first PDSA cycle showed that the 4AT was feasible for use by healthcare assistants on the surgical assessment unit (SAU). A second PDSA cycle, described here, sought to develop a rationale for implementation of the 4AT as part of surgical assessment by comparing true prevalence of delirium using 4AT, with the prevalence detected using methods currently mandated by our hospital. All patients aged ≥65 years admitted as part of the surgical pathway had 4AT completed by a member of our improvement team on admission, with daily review until discharge.

Results
Data were collected for 111 consecutive emergency surgical admissions. Mean (SD) age was 78.3 (7.7) years. Of these, 1 and 3 were categorised as having delirium and dementia respectively using existing hospital screening tools. Using 4AT, 36 (32%) of patients were identified as having delirium. When supplemented by clinical history, true prevalence was 40 (36%). Average (SD) length of stay was 7 (5.6) days for the whole cohort, 10 (6.5) and 5.3 (4.3) days for those with and without delirium respectively.

Conclusions
4AT was 92% sensitive for delirium in our cohort. The existing hospital tool was underutilised to the point of being useless. Patients with delirium had a longer length of stay. We have developed a modified 4AT paper tool and training materials and are now piloting routine use in SAU.
81 Integrating A Front Door Frailty Service in the Emergency Department: Results of A Pilot Study
Authors: Dunnell L , Shrestha A , Li E , Khan Z , Hashemi N 
Published: March 2021

Abstract

Introduction
Increasing old age and frailty is putting pressure on health services with 5–10% of patients attending the emergency department (ED) and 30% of patients in acute medical units classified as older and frail. National Health Service improvement mandates that by 2020 hospital trusts with type one EDs provide at least 70 hours of acute frailty service each week.

Methodology
A two-week pilot (Monday–Friday 8 am-5 pm) was undertaken, with a “Front Door Frailty Team” comprising a consultant, junior doctor, specialist nurse and pharmacist, with therapy input from the existing ED team. They were based in the ED seeing patients on arrival, referrals from the ED team and patients in the ED observation ward—opposed to the usual pathway of referral from the ED team to medical team. Data was captured using “Cerner” electronic healthcare records. A plan, do, study, act methodology was used throughout with daily debrief and huddle sessions.

Results
95 patients were seen over two weeks. In the over 65 s, average time to be seen was 50 minutes quicker than the ED team over the same period, with reduced admission rate (25.7% vs 46.5%). The wait between decision to admit and departure was shortened by 119 minutes. Overall, this led to patients spending on average 133 minutes less in the ED. 64 patients were discharged, of which 44 had community follow-up (including 37.5% of 64 referred to acute elderly clinic and 25% to rapid response). 47 medications were stopped across 25 patients.

Conclusion
The pilot shows that introduction of an early comprehensive geriatric assessment in the ED can lead to patients being seen sooner, with more timely decisions over their care and reduction in hospital admissions. It allowed for greater provision of acute clinics and community services as well as prompt medication review and real time medication changes.
85 Improving Rates of Medication Prescription on Admission by the Clerking Doctor in Patients with Neck of Femur Fractures
Authors: Ang R J , Haye B , Noden S , Al-Saffar B Y 
Published: March 2021

Abstract

Introduction
Ensuring correct medications are prescribed for all patients admitted with neck of femur fractures is essential for presurgical optimisation, analgesia and perioperative care. This quality improvement project examines patients over the age of 65 who were managed following the orthogeriatric pathway for all neck of femur fractures at Queen Elizabeth Hospital, Woolwich. Guidelines exist that include a list of medications that should be prescribed for all of such patients on admission, including VTE prophylaxis, analgesia, antiemetics, laxatives, IV fluids and preload. The aim is to improve the rate of following this guidance on prescription by clerking doctors on admission.

Method
Data was collected retrospectively for all patients admitted to Queen Elizabeth Hospital between 03.12.19–15.01.20 with a neck of femur fracture. Interventions were then introduced to improve medication prescriptions and took place at the start of February 2020. This involved tutorial sessions and raising awareness through posters. Data collection for cycle 1 following interventions took place from 03.02.20–14.03.20 and can be compared with the original baseline data set.

Results
Data was collected from 34 patients for the baseline population and 28 patients in Cycle 1. Baseline data suggests that certain medications, such as preload and TEDs stockings were often missed by the admissions team, with only 8.82% of patients receiving 9 pm preload, 17.6% receiving 6 am preload and 38.2% prescribed TED stockings. Following interventions, medication prescriptions by the clerking doctors improved in all parameters, with significant improvements seen with VTE prophylaxis.

Conclusion
Induction sessions and accessible guidelines are essential to ensure guidelines are followed and patients receive correct medications on admission. Improving medication prescriptions is vital for medical optimisation prior to surgery and to lower rates of perioperative complications. Clerking doctors responsible for this task should receive correct training and support to ensure this is done correctly.
86 Reducing Inappropriate Readmissions From A Community Hospital—A Quality Improvement Project
Authors: Ronan D , Meadows L , Latcham N , Melrose R 
Published: March 2021

Abstract

Introduction
Quality person-centred care in those approaching the end of life includes consideration and anticipation of their preferred place of death and ceiling of care (CoC). This QI project to reduce inappropriate readmissions was prompted following the transfer of a palliative patient to the acute trust from a community hospital.

Method
Data was collected from the electronic patient record (EPR) at weekly intervals over a six month period, July to December. Electronic documentation of CoC from 507 records from a 24 bed community hospital was reviewed. Data collected included patient age, sex and whether a CoC decision entry had been made on the EPR during the community hospital inpatient stay. The appropriateness of readmissions over the same period was also analy sed. A weekly consultant geriatrician ward round was introduced focusing on advanced care planning with explicit decision making regarding preferred place of care.

Results
There were a total of 16 readmissions during the study period. 3 of these were deemed “inappropriate” following EPR review occurring in August, September and October. Subsequent review of electronic CoC July to October inclusive demonstrated a median completion rate of 20.5%. Following intervention there were no further inappropriate readmissions and the median CoC completion rate was 85%. Qualitatively, the consultant geriatrician managing the community hospital felt there had been a cultural shift where staff felt more comfortable managing complex palliative care.

Conclusions
Introduction of a weekly Consultant Geriatrician ward round in the community setting has led to a sustained improvement in CoC decision-making and documentation. As a result of this there have been no further inappropriate readmissions to the acute trust. This reflects the national guidance in patient centred palliative care. Further work including robust, qualitative assessment of staff attitude towards palliative care is needed to emulate this work at other local community hospitals.
88 Improving Clinical Effectiveness At Identifying Patients Requiring Advanced Care Plans
Authors: Nemchand P , Hassan D , Steel A 
Published: March 2021

Abstract
Our project was conducted in a district general hospital across five acute geriatric wards. Our team included consultants, registrars, and ward matrons. The project focused on improvement of care for geriatric inpatients, with moderate to severe frailty. Advanced care planning (ACP) columns are displayed on white boards. They indicate whether ACPs are required/initiated for each patient. When previously utilised, ACPs were initiated for 78% of appropriate patients [1]. Following a change in staff and reduction in awareness/education, the ACP column use reduced with fewer ACPs established.
Our goals were to ensure completion of the ACP column, encourage junior doctor/nurse involvement and trigger a greater number of appropriate ACPs initiated Improvement in ACP practice was addressed by daily board round review of appropriate patients for ACP, increasing awareness of ACP triggers and education around discussion content. Interventions consisted of: 1, a flow-chart adjacent to white boards prompting “Do not attempt resuscitation (DNAR)” and ACP processes. This signposted staff to information on ACP triggers and “how to start a conversation”. 2 Involving registrar “champions” on each ward. We explained our intervention to all team members to encourage engagement.
Data from the ACP columns were audited prior to intervention, 2 weeks and 6 weeks after intervention. There was a 54% increase in ACP documentation after 6 weeks across the wards.
The improvement in the use of the ACP column correlated with a greater number of ACPs initiated. This facilitated an increase in consideration of patient wishes towards the end of life. Increasing use of a daily ACP prompts on board rounds triggers an increase in ACP implementation for appropriate patients. Sustainability was achieved by recruitment of ward “ACP champions”. Junior doctors/matrons were more empowered to discuss ACPs. Results were presented at departmental teaching to reinforce the positive impact of the intervention.
91 Mrs Bad Bones: Impact of COVID-19 on Secondary Prevention of Fragility Fractures
Authors: Stephens A , Rudd H , Stephens E , Ward J 
Published: March 2021

Abstract

Introduction
Management of osteoporosis is an important consideration for neck of femur fracture patients due to the morbidity and mortality it poses, and the significant financial burden to the NHS. Orthogeriatric teams input is invaluable in coordinating secondary fragility fracture prevention. The COVID-19 pandemic resulted in the rapid restructuring of healthcare teams and led to the redeployment of the orthogeriatricians to assist with the influx of medically unwell patients. This study explored the impact COVID-19 had on secondary fragility fracture prevention.

Method
A retrospective audit looking at the prescription of vitamin D/calcium supplements, bone-sparing medications, and DEXA scan requests in consecutive neck of femur fracture patients admitted to a trauma and orthopaedic unit pre- and post- UK lockdown in response to the pandemic. A re-audit was conducted following the implementation of our new mnemonic, “MRS BAD BONES”: Medication Review Rheumatology/Renal Advice Smoking Cessation Blood tests Alcohol limits DEXA scan Bone-sparing medications Orthogeriatric review Nutrition Exercise Supplements.

Results
Data for 50 patients was available in each phase. The orthogeriatric team reviewed 88% of patients pre-lockdown falling to 0% due to redeployment, before recovering to 38% in the post-intervention period. Upon lockdown there was a significant drop in the prescription of vitamin D/calcium supplements from 81.6% to 58.0% (p = 0.0156); of bone-sparing medications from 60.7% to 18.2% (p = 0.0037), and DEXA scan requests from 40.1% to 3.6% (p = 0.0027). Following the implementation of our mnemonic, there was a significant increase in the prescription of vitamin D/calcium supplements to 85.7% (p = 0.0034), bone-sparing medications to 72.4% (p = 0.0002) and DEXA scan requests to 60% (p &lt; 0.0001).

Conclusion
COVID-19 had a major impact on the secondary prevention of fragility fractures in this population. The “MRS BAD BONES” mnemonic significantly improved the management and could be considered for use in a wider setting.
97 Prescribing of Hypnosedatives in Seniors in Ambulatory Care in the Czech Republic: Inomed and Euroageism Project Findings
Authors: Antonenko O , Puldová K , Halačová M , Grešáková S , Brkic J , Fialová D 
Published: March 2021

Abstract

Introduction
Among psychotropic drugs, particularly hypnotics are often used by ambulatory seniors due to high prevalence of insomnia in higher age. This study focused on describing the prevalence of insomnia, prevalence of hypnosedative drug use and inappropriate patterns of their prescribing (nongeriatric doses, nongeriatric lenght of therapy) in ambulatory seniors in the Czech Republic.

Methods
There were 563 ambulatory geriatric patients (≥65 years) included in the study, from 4 geriatric ambulances (regionally different sites) in the Czech Republic. All patients have been assessed using comprehensive geriatric assessment (CGA) using the EUROAGEISM H2020 study protocols. Prevalences of insomnia, hypnosedative drug use and use of drugs that may exacerbate insomnias were documented by descriptive statistics, as well as the prevalence of potentially inappropriate medications in older patients (PIMs, selectively for hypnosedatives, defined by 2019 Beers criteria and 2015 EU(7)-PIM list).

Results
30.6% (N = 172) of ambulatory seniors suffered from insomnias and the majority of patients were treated pharmacologically (24.0%), nonpharmacologic procedures were used rarely (0.5%). Hypnosedatives in the evening or at night (e/n) were mostly prescribed in the age group of patients 84–94 years (42.8%) and most often these were Z-drugs (8.2%), benzodiazepines (BZDs, 7.6%) and from „off-label “hypnotics antipsychotics (17.8%,!17% of users 6 months) and sedative antidepressants (9.2%). In nongeriatric doses and nongeriatric duration of therapy (&gt;4 weeks) there were most often prescribed Z-drugs (6.0% and 2,7%, respectively) and BZDs (2,7% and 11%).

Conclusion
In ambulatory Czech seniors we documented that one third suffered from insomnias and minimally were applied nonpharmacological treatment strategies. From nongeriatric procedures in hypnosetive drug use were most often described long-term use of antipsychotics e/n, non-geriatric 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.
100 Frailty Hot Clinics: Rapid Cga and Speciality Diagnostics Reduces Rates of Hospitalisation and Re-Attendance
Authors: Lim H J , Robson R , Alexander N , Cunningham R , Encisa D , Jhurry R , Owusu D , Remolan A 
Published: March 2021

Abstract

Introduction
Acute hospitalisation is associated with an increased risk of progressive frailty, morbidity and subsequent institutionalisation. North Middlesex University Hospital is an Acute District General Hospital with over 550 attendances to A&E per day. Comprehensive Geriatric Assessment (CGA) is the gold standard approach for a holistic multi-disciplinary assessment (MDT) of frail patients. A rapid access daily hot clinic service for frail patients opened using quality improvement (QI) methodology to deliver rapid CGA focusing on admission avoidance and early supported discharge.

Method
4 PDSA cycles were conducted. A process map identifying key moments in patient care was derived from time studies of the first 10 patients’ journeys. Patients were triaged through the Geriatrician “hotphone” for acute admissions into the Hot Clinic. Dedicated clinic and waiting rooms were placed on the acute frailty unit (Amber) staffed by a dedicated Consultant Geriatrician and Health Care Support Worker working with the Frailty Ward Clerk, Frailty Specialist Nurse, Therapies, specialities in-reach and same-day diagnostics. A shared clerking proforma and subsequent CGA Discharge Summary were completed and emailed to the referrer the same day. Qualitative and Quantitative feedback was gained from referrers, patients and relatives through a structured questionnaire. Metrics were gathered including rate of admissions, re-attendance and use of enhanced community services.

Results
From the first 48 Hot Clinic patients, there was a low 30-day re-attendance rate (17%—for unrelated reasons), low 30-day re-admission rates (4%) and low Did Not Attend rate (6%) for new referrals and high satisfaction scores for recommending the service (9-10/10) from patients, relatives and referrers.

Conclusions
Early rapid MDT can reduce re-attendances and re-admissions to hospital in frail patients. A streamlined patient journey can be delivered by frailty-trained staff and in a suitable environment. QI Methodology enables a structured measurable approach to development of the Acute Frailty Pathway.