bluuebunny/crossref_metadata_2025_split huggingface dataset:
294 A Review of a Domiciliary-Based Multidisciplinary Integrated Care Service with Healthcare Assistant Home Support – Is this the Optimum Model?
Authors: Boyle Nichola , McDonnell Sinead , Balasubramanian Subha , Reynolds Niamh , Geary Niamh , Fegan Peter , O'Shea Diarmuid , Hession Eilis 
Published: September 2019

Abstract

Background
The Integrated Care Programme for Older People has supported the development of integrated care services at pioneer sites in Ireland. Key to integrated care is embracing a move away from hospital based assessment and therapy provision, especially for re-ablement and home support care planning, to assessment in the home: “discharge to assess”.

Methods
The Older Persons’ Integrated Care Team (OPICT) provides a targeted, multidisciplinary domiciliary-based re-ablement programme of care to people aged 65 years and older. Using PDSA methodology for service improvement, the addition of home support provided by healthcare assistants (HCAs) was introduced and evaluated. Data was collected prospectively on baseline service user demographics, service activity and outcome measures. HCA delivered home support services were introduced in November 2017. This study contains data for the period November 2017 to March 2019.

Results
Since May 2017, OPICT has provided 266 episodes of domiciliary-based re-ablement to 248 clients, with a further 90 clients assessed but ineligible. The median age of clients was 84 years (8% 65-74 years; 49% 75-84 years; 37% 85-94 years; 6% 95 years and older). The majority of clients were female (58.5%), with low dependency (Barthel score 16 to 19) and classified as vulnerable to moderately frail based on the Clinical Frailty Scale (scores 4 to 6). Of 215 eligible clients, 122 received a total of 1293 hours of healthcare assistant delivered care. Flexibility in the availability of carers to meet demand and willingness of HCAs to embrace a more diverse role were important learning points.

Conclusion
The “discharge to assess” model of integrated care for older people can be achieved in the Irish healthcare setting, with access to flexible HCA delivered home support a key element.
310 Impact of an Integrated Care Hub on Access for the Community to In-patient Rehabilitation: Right Place, Right Time
Authors: O'Gorman Millie , Wall Triona , Naughton Christina , Phelan Niamh , Murphy Catherine , Gantly Thomas , Whyte Caitriona , Bolger Maggie , Brennan Jacinta , Doyle Marie , O'Donoghue Alice , Harnett PJ , Pope George , John Cooke , Mulcahy Riona 
Published: September 2019

Abstract

Background
The Inpatient rehabilitation service serves a population of 116,176 of whom 17,371 are aged 65yrs and over. Access to these units was traditionally via referral from the acute hospital sector with the minority of referrals coming from the community.
Review of the existing rehabilitation pathway was undertaken and highlighted barriers of access to appropriate in-patient rehabilitation. The referral criteria were revised and an updated pathway was devised.

Methods
A quantitative retrospective review of all referrals received in four timeframes, commencing 1st July 2017 to date, was carried out. Each referral was classified into four subgroups: (1) Immediate Crisis (2) Emerging Crisis (3) Stable but Needs Optimisation (4) Stable and No in-patient Intervention required. The origin of the referral was also categorised into four subgroups: (1) Day Hospital (2) GP (3) AHP (4) Other. The Average Length of Stay (AvLoS) was calculated for, acute and community admissions, for each period breakdown.

Results
We compared 1st July 2017 to 31st December 2017 pre-establishment of the new referral pathway and the same six month period in 2018 post-establishment of the pathway. The new streamlined pathway facilitated improved access to in-patient rehabilitation from multiple sources and resulted in an increase in referrals from 25 to 79. Waiting time for admission was reduced from 37 days to 5 days. Community admissions increased from 16 to 48. There was no difference in AvLoS between the two time periods: Acute 22 & Community 17 to Acute 22.25 & Community 18.

Conclusion
This work highlights the effectiveness of an improved co-ordinated referral pathway, within an integrated care hub, from community to in-patient rehabilitation beds with improved accessibility and reduced waiting times. AvLoS figures suggest that appropriate patients were admitted to the rehabilitation units. Also, it confirms the efficiency of a patient centred approach in maximising appropriate services for Right Person, Right Place, Right Time.
322 Major Trauma in the Older Person - Major Challenges Ahead
Authors: Doyle Rachael , Brent Louise , Connolly Aisling , Breslin Tomas , Jones Sophie , Kelly Fionnola , Lawrence Tom , Deasy Conor 
Published: September 2019

Abstract

Background
The mean and median age of major trauma continues to increase for a mean of 36 years in the 1990's to 59 and 61 years respectively in 2016 and 2017. The age planning of major trauma has important implications for healthcare planning.

Methods
The major trauma audit was established by the National Office of Clinical Audit (NOCA) in 2013 and focuses on the most severely injured trauma patients in our healthcare system. The methodological approach is provided by the Trauma Audit and Research Network (TARN). Since 2016 all 26 eligible hospitals have been participating in the audit and the coverage is now 86%.Data has been collected on more than 15000 trauma patients to date.

Results
There were 5061 recorded major trauma cases of which 2233 (44%) were over 65 years in 2017. The most common form of injury (57%) was falls less than two metres (low falls) and this began aged 45 years. 50% of injuries occurred in patient's own home. Only 11% of people were received by a trauma team and this was even lower in the older adult. Older people were very unlikely to be pre-alerted to the Emergency Department prior to arrival. 64% of the mortality from major trauma occurred in the over 65 years. 6%, 7% and 10% of patients aged 65-74, 75-84 and over 85's respectively were discharged directly to nursing home.

Conclusion
There is a marked change in the age profile sustaining major trauma since the late 1990's. Patients today are older with more complex medical needs, have greater lengths of stay and many do not return to independent living. The most common mechanism of injury for older people is a low fall at home. We need to prevent low galls using a multidisciplinary, multi-agency approach.
201 A Re-audit of Lignocaine 5% Medicated Plaster (Versatis®) Prescribing in an Older Adult Inpatient Population Following Changes to Reimbursement Provisions
Authors: McCartan Deirdre , Poff Alison , Lee Stuart , Martin Alan 
Published: September 2019

Abstract

Background
Lignocaine 5% medicated plasters (Versatis®) are licensed only for treatment of postherpetic neuralgia. Our 2017 audit of Versatis® prescribing recorded a potential cost of €28,297/year for just 26 patients, all off-label. We noted however the limited choice of analgesics in older adults due to co-morbid conditions such as CKD and frailty. The 2017 Medicines Management Programme (MMP) directive for label-only Versatis® prescribing aimed to reduce annual exchequer costs of €30 million noting 25,000 people had prescriptions under Community Drugs Schemes (CDS) in 2016.

Methods
We conducted a re-audit of Versatis® prescribing on five core geriatric medical, orthogeriatric and rehabilitation wards across three inpatient sites. Indication for, duration of and patient's personal view of the plaster was recorded. Pharmacy provided medications costings. Cost per day and per length of stay were calculated. All other prescribed analgesics were recorded.

Results
Analgesics prescribed for 127 patients were recorded. Mean age was 81 years, 63% female. 4/127(3%) were prescribed Versatis® compared to 26/129(20%) in 2017, all off-label.Indications included osteoarthritis and spinal stenosis. All four patients were prescribed the plaster prior to admission. Cost per plaster was €3.46 compared to €2.58 in 2017. Cost of Versatis® for these 4 admissions was €346 for their combined 100 bed days. Total cost of co-prescribed paracetamol for these four patients was €45.90. Three patients noted little analgesic benefit, one felt the plaster a psychological support. Seventeen different analgesics were prescribed across 127 kardexes.

Conclusion
No patient was newly prescribed Versatis® during their admission. The MMP directive for the prescribing of Versatis® influenced prescribing practice across our hospital sites. Community practice for prescribing off-label is still evident for chronic pain, reflecting the difficulty of pain control in older adults. The cost of individual plasters increased by 0.88€ since 2017.
208 Life Course Socioeconomic Position and Allostatic Load Burden
Authors: McLoughlin Sinead , McCrory Cathal 
Published: September 2019

Abstract

Background
Allostatic load (AL) is a measure of cumulative physiological dysregulation that is posited to capture the ‘wear and tear’ on the body resulting from exposure to chronic stress. AL has been shown to predict disease, morbidity and mortality. Multiple studies have shown an inverse relationship between AL and SEP, but few have examined the life course social patterning of AL.

Methods
Using baseline data from The Irish Longitudinal Study on Ageing (TILDA), an AL index was calculated by summing the number of biomarkers for which respondents fell within high risk quartiles. 17 biomarkers were examined, representing cardiovascular, immune, metabolic and parasympathetic nervous systems. SEP and life course trajectories were determined using father’s occupation (at age 14) and current occupation, which were aggregated to create four categories of social mobility; stable high, downwardly mobile, upwardly mobile and stable low. Negative binomial regression models were fitted for each of the life course models of critical period, accumulation and social mobility, to examine the associations between SEP and AL (n=3,282).

Results
Higher SEP was associated with lower AL. A significant association between origin SEP and later life remained after controlling for destination SEP. The ‘stable high’ across the life course had the lowest AL burden, the ‘stable low’ had the highest burden, and the mobile groups ranked intermediate.

Conclusion
Findings suggest childhood to be a sensitive period for the embedding of early life disadvantage. The accumulation hypothesis suggests that those who spend more time disadvantaged fair worse in terms of health. This study supports this hypothesis, as those who were stable low / stable high were in the worst / best health respectively.
214 Advance Care Planning: Perspectives of People with Dementia and their Family Members
Authors: Coimín Diarmuid Ó , Ferguson Liz , Beaumont Clíona , Sheridan Sheighle , Kyne Lorraine 
Published: September 2019

Abstract

Background
Clear and effective communication is central to all aspects of healthcare. Discussions centred on advance care planning are vital to ensure the person with dementia receives the support and care they need in the future based on their will and preferences. The aim of this study was to ascertain from those provided with information on advance care planning if it met their needs and assisted their understanding on planning for the future.

Methods
This study centred on eliciting the views of older persons diagnosed with dementia and their carers on the provision of an information booklet titled ‘I have dementia ... How do I plan for the future’. Ethical approval was sought and provided to conduct this study. Participants presenting to an acute hospital day ward for older persons were identified and recruited through the medicine for older person’s team. 42 people consented to participate with 20 people returning questionnaires, a 48% response rate. Thematic analysis was applied to qualitative comments and descriptive statistical analysis was undertaken with quantitative data.

Results
The overwhelming majority (95%) of respondents found the provision of an information booklet on advance care planning helpful. Nearly two thirds (65%) spoke with someone about advance care planning thereafter. 60% of all respondents reporting that the booklet was either ‘easy’ or ‘very easy’ (40%) to understand. Participants strongly endorsed the provision of information on advance care planning and the benefits that it bestowed to them.

Conclusion
The study has confirmed the importance of communication and the provision of information on advance care planning for people with dementia and their carers in the day ward setting for older persons. Findings strongly endorse the information provided whilst also suggesting minor amendments to the booklet to improve future editions.
219 The Effect of Introducing In-house Radiographers Out of Hours on Door to CT Times for FAST Positive Patients
Authors: Hobson Helen , Cogan Nicola , Greene Suzanne , Ryan Dan 
Published: September 2019

Abstract

Background
Stroke is a leading cause of death and disability in Ireland with up to 7,000 people hospitalised following a stroke annually (IHF/HSE 2016). Every minute in which a large vessel ischaemic stroke is left untreated equates to the average patient losing 1.9 million neurons (Saver, 2006). With the introduction of out of hours in-house radiographers our aim was to look at how this impacted on the service of care to FAST positive patients who present to our Emergency Department. Stroke is a medical emergency where urgent assessment and treatment can lead to improved survival and reduced disability.

Methods
To assess the impact of the introduction of in-house radiographers out of hours we compared door to CT times of FAST positive patients who presented to ED out of hours pre and post the introduction of in-house radiographers. We took the first 30 FAST calls following the introduction of the in-house radiographers and compared those times to the last 30 FAST calls prior to their introduction.

Results
Preliminary results have shown that the introduction of in-house radiographers has reduced the median time spent in the Emergency Department times prior to CT imaging. Current median door to CT times prior to the introduction of in-house radiographers was 27 minutes, the median door to CT time post introduction of in-house radiographers is 21 minutes, however full results are still awaited.

Conclusion
The introduction of in-house radiographers out of hours has led to a quicker transition of patients from the Emergency Department to the CT department thus reducing door to CT times.
230 The Impact of a Palliative Care ECHO Programme on Symptom Severity Scores and Phases Score in a Nursing Home Population
Authors: Murphy Claire , Molloy Una , McLean Sarah , Ryan Daniel 
Published: September 2019

Abstract

Background
In Ireland most deaths occur in acute hospitals however 20% of deaths occur in residential facilities. Less than 30% receive specialist palliative care input. ECHO (extension for community healthcare outcomes) is a palliative care education programme consisting of a 10 part lecture series. Twenty nursing homes and 353 staff participated. A phases score is a 5-point rating scale classifying the status of a palliative care patient ranging from stable to bereaved.

Methods
Data collected by palliative care professionals from September 2017 to December 2018 was analysed. This included demographic features, a phases score and scores for pain, carer stress, spiritual and psychological need. Nursing homes that attended ≤ 3 ECHO sessions were excluded, 15 participating nursing homes were included. Age matched control subjects were selected from non-participating nursing homes on a 2:1 basis. Data was analysed using the paired T Test and Chi squared was analyzed for frequency data.

Results
There were 40 patients in the intervention group and 80 in the control group. Mean ages were 83yrs and 82yrs respectively. Palliative care referral numbers did not change significantly between the two groups (111 and 114). The Phases score was significantly reduced in the ECHO group compared to controls (P=< 0.007). There was no significant reduction in the phases score in the ECHO group pre and post intervention (P=0.29). There was no difference in Pain scores between groups (P=0.98)

Conclusion
The ECHO intervention led to a reduction in the overall phases score in participating nursing homes. This was not the result of increased palliative care referrals. We would infer it is a reflection of better control of symptoms overall. We did not demonstrate a significant reduction in individual symptoms. The phases score is an overall representation of a patient’s status. With the expansion of the ECHO programme on-going analysis will be performed.
233 Potential Deprivation of Patient Liberty: A Qualitative Study of Current Practice Amongst Geriatricians in a Tertiary Setting
Authors: O'Brien Michelle , O'Donnell Deirdre , Clyne Barbara 
Published: September 2019

Abstract

Background
The Assisted Decision Making (ADM) Act 2015 was introduced to support decision making and maximise a person’s capacity to make decisions but has not yet commenced. Within this context, medical professionals such as geriatricians must adjust from a best interest’s outlook to that of patient autonomy in response to the changing legislation. The aim of this study is to explore current geriatrician’s practice. In scrutinizing current practice, it will be evident as to what, if any, adaptations are required in order to practice in accordance with the new legislation.

Methods
Ten semi-structured interviews with individual consultant geriatricians were conducted, each lasting approximately 20 minutes on average in one hospital. Each interview was recorded and transcribed verbatim. The interview involved the geriatrician reading a vignette and answering questions as to how they would manage this situation. Following the vignette, the semi-structured interview proceeded covering topics including; patient decision making in the acute setting, deprivation of patient liberty in the acute setting, thoughts on the ADM (Capacity) Act 2015, and elements learned from experiences in other countries. A thematic analysis was conducted.

Results
Preliminary themes identified from the interviews include; (a) identification, accessibility and availability of medical and legal colleagues in assisting with difficult decision making, (b) need for clear frameworks, guidance and education in relation to laws applying to medical practice, (c) influence of environment, family, perceived risk and delirium on capacity assessment, (d) paternalism versus autonomy. This work is being conducted as part of a master’s in healthcare ethics and law.

Conclusion
Preliminary results highlight the need for collaborative communication between medics and the legal profession in order to achieve a structured and supportive framework to inform practice considering the new legislation.
238 Bridging the Gap: Expanding and Improving the Role of the Integrated Care Team in a Level 4 Hospital
Authors: Fitzpatrick Donal , Heywood Sarah , O'Mahony Catherine , Gallagher Paul 
Published: September 2019

Abstract

Background
The traditional model of acute episodic care for older people is reactive and outdated. The integrated care team (ICT) was introduced in April 2017. It comprises a physiotherapist, occupational therapist, clinical nurse specialist and case manager and provides intensive rehabilitation at home to frail older adults after an acute presentation to hospital, thus bridging acute hospital care and coordinated longitudinal care in the community.

Methods
We evaluated the integrated care team referral database as well as discharge letters from July to November 2018.

Results
Over 5 months, 45 out of approximately 90 referrals were deemed appropriate for the ICT. Almost half of referrals were unsuitable because of medical acuity or specific instructions such as being unable to weight-bear. Over half of referrals came from the emergency department with no referrals from general surgery, orthopaedics or cardiology. During the time of review, the service was operating at <85% capacity. There is no specific registrar assigned to review ICT referrals. The service is expanding with 123 referrals in six months, compared to 54 in the same period the previous year.

Conclusion
The integrated care team helps older adults to avoid hospital admission, return home sooner and regain independence and is a much-appreciated service in the area. We identified shortcomings in the referral process, formal medical oversight and awareness of the service in areas where it could provide the most value. The ICT can expand as a key asset for frail older adults if supported by the necessary resources, staffing, consultant geriatrician leadership, referral criteria and pathways and is promoted and publicized in the clinical settings where it has the greatest potential for benefit.
241 “From SIAD to Happy”: a Case of Effective Use of Tolvaptan for Hyponatremia in an Older Person
Authors: Costello Maria , Newman Christine , Loughlin Elaine , Canavan Michelle , Bell Marcia , Robinson Stephanie 
Published: September 2019

Abstract

Background
Hyponatremia commonly affects the older person, leading to morbidity and mortality. Tolvaptan use is rare in this cohort, but may have benefit in select cases of syndrome of inappropriate antidiuresis (SIAD).

Methods
An 84-year-old gentleman presented with a history of increasing confusion, fatigue and lethargy attributed to symptomatic hyponatremia. He had background of a recent prolonged admission with small bowel obstruction, treated conservatively. That hospital course was complicated by hypovolaemic hyponatremia, sepsis and clostridium difficile colitis. On this admission, he had no clinical symptoms or signs of infection and his septic screen was negative. He had a Rockwood clinical frailty scale score of 7. His biochemical abnormality was a persistent hyponatremia of 129 mmol/L. Clinically, he was euvolaemic. Further biochemical work up revealed serum osmolality of 263 mmol/kg, serum urea of 6.3 umol/L, urine sodium 108 mmol/L and urine osmolality 541 mmol/kg. Thyroid function, cortisol, and HbA1c were normal. CT brain and chest x ray were unremarkable. A diagnosis of SIAD was made. Fluid restriction was ineffective and Tolvaptan (a selective non-peptide arginine vasopressin receptor antagonist) was commenced on consultation with Endocrinology.

Results
With initiation of Tolvaptan there was significant clinical improvement. Sodium normalised to 134 mmol/L. He became alert, less confused and more engaged with the multidisciplinary team. He was discharged home well, and on follow up four months later, his clinical frailty scale score was 4 with significant improvement in his mobility on continued Tolvaptan therapy. An underlying colonic neoplasm is the clinically suspected driver of his SIAD but he is declining further investigation at present.

Conclusion
This case reflects the positive benefits of careful selected use of Tolvaptan in the older population with refractory SIAD, resulting in improved functional status and quality of life.