bluuebunny/crossref_metadata_2025_split huggingface dataset:
2254 Improving the quality and breadth of advance care planning discussions on gerontology wards in an acute London trust
Authors: Curtis T , Crabtree S , Al-Hashimi S , Hasan S , Osborne G 
Published: August 2024

Abstract

Introduction
Advance care planning (ACP) offers people the opportunity to plan their future care whilst they have capacity to do so and is supported by national guidance. Decisions regarding future care are more likely to be individualised and holistic when patients and their significant others are involved. This QI project aimed to address this by increasing the frequency of ACP discussions being offered and recorded on gerontology wards in an acute London Trust.

Method
A multi-professional steering group was established to improve ACP using PDSA methodology. A new ACP toolkit, training programme and electronic flowsheet (within the hospital’s patient record system) were implemented. ACP documentation quality was audited on gerontology wards pre and post implementation (over one to four months respectively). Data was compared using Pearson’s Chi-squared test.

Results
ACP flowsheets were completed by junior and senior doctors, and clinical nurse specialists in frailty and palliative medicine. The initial audit found disparity between documented topics of ACP conversations, with cardiopulmonary resuscitation recommendations being most discussed. Post implementation, 24 ACP flowsheets were reviewed, showing that more ACP topics were documented where these conversations were had; preferred place of death increased from 24% to 60% (p 0.011); treatment escalation plan increased from 41% to 75% (p 0.014); preferred place of care increased from 59% to 71% (p 0.066). Topics not showing significant improvement in documentation (despite inclusion in the flowsheet) were spiritual needs, information needs and prognostic discussion, broader social needs and what was most important to the patient.

Conclusion
The implementation of an electronic ACP flowsheet improved documented ACP conversations in some topics, guiding healthcare professionals to deliver care that aligns with peoples’ wishes and preferences. Documented conversations became easier to access, review and audit. Work is still needed to promote ACP conversations being centralised around what matters most to patients.
2145 Physical and mental health needs of older transgender adults in the U.K.: a scoping review
Authors: Knox C , Wells L , Shrewsbury D , Levett T 
Published: August 2024

Abstract

Introduction
The number of adults in the UK who identify as transgender is increasing, through greater recognition of trans identity and growing numbers of individuals transitioning in later life. The term ‘Transgender’ encompasses a diverse range of experiences and identities, including those who identify as non-binary, gender-fluid, and gender-queer. However, within this review, we use the shortened term ‘trans’ and the following broad definition: ‘people whose gender is different from the gender assigned to them at birth.’ We conducted this exploratory review to examine the literature regarding the specific health and social care needs of older trans adults.

Methods
We utilised scoping review methodology and thematic qualitative analysis to systematically search and map the literature related to the physical and mental health challenges related to the ageing experience among trans adults in the UK.

Results
We identified 22 relevant papers through combined systematic search and additional manual reference review. We recognised five key themes within the literature: Systems and Structural Factors, Health and Mental Health, Social Care, Diversity and The Future. The former three themes relate to limitations presented by current models of care, barriers within services and potential areas for development. Key areas identified include challenges related to the application of a binary gender model within healthcare systems as well as advanced care planning and ensuring gender-affirming care where capacity is lost including living with dementia. The latter two themes identify gaps in the current literature and provide examples of trans-inclusive positive practice.

Conclusions
There is an ongoing need for researchers, clinicians and policymakers to ensure that the needs of older trans adults are studied, understood and accommodated within policy and practice. Service providers delivering care to older adults must understand trans-specific needs, particularly around advanced care planning, to ensure that trans people are supported to age well.
2168 A survey of non-consultant hospital doctors’ perspectives, knowledge, and practices towards delirium in a large Irish hospital
Authors: Hassabo M , McCluskey P , Browne J , Ntlholang O 
Published: August 2024

Abstract

Background
Delirium is a common condition in hospitals, especially among older people. This refers to a dramatic decline in mental capabilities marked by diminished concentration and consciousness.

Aims
The purpose of this study is to assess the views, knowledge, and behaviour of non-consultant hospital doctors about managing delirium in a large Irish hospital.

Methods
Questionnaires were given to 28 healthcare professionals from various departments according to Davis and MacLullicin (2009). It was conducted between July and September 2023 with emphasis on finding out its prevalence rate, diagnostic criteria, and management strategies for delirium.

Results
The study established that majority of the respondents recognised the importance of delirium but there appears to be a gap in practical management of this clinical syndrome. Although many doctors agreed that delirium was significant, most lacked confidence in diagnosing as well as managing it. The use of standardised assessment tools like the 4AT was limited.

Conclusions
This study highlights the disparity between what is known and practiced by hospital doctors concerning delirium care. It implies increased training for delirium management with frequent use of assessment tools and ongoing education aimed at enhancing patients’ outcomes during cases of delirium.
Keywords: Delirium Management, Hospital Doctors, Medical Training, 4AT, Clinical Practice, Elderly Care.
2233 Incidence of inappropriate CPR in the emergency department—is ReSPECT making a difference?
Authors: Lisseter A 
Published: August 2024

Abstract

Introduction
A BMJ study suggested that 1 in 5 sick, older patients have a ‘do not resuscitate’ document and a large proportion only had this completed in the Emergency Department (ED) (1). Current ED pressures could cause greater delay in this discussion, resulting in inappropriate cardiopulmonary resuscitation (CPR). The ReSPECT form was established to bring consistency to the communication of patients wishes, including ‘do not attempt CPR’ (DNACPR) (2). This QUIP assessed the incidence of inappropriate CPR in two ED’s by investigating the proportion of CPR performed on those with a prior DNACPR or ReSPECT form.

Method
Data was collected retrospectively from cardiac arrests in two ED’s between the 1st of January 2023 and the 17th of November 2023. The three parameters assessed were the number patients undergoing CPR, number with prior DNACPR/ReSPECT forms, and how often CPR occurred within 30 minutes of patient arrival. Hospital A used ReSPECT forms, whereas Hospital B did not.

Results
Over the assessed period, CPR was performed on 21 patients at Hospital A. Of these, 19% had prior DNACPR/ReSPECT forms and 43% of CPR was within 30 minutes of patient arrival. 10 patients received CPR at Hospital B. Of these, 0 patients had prior DNACPR/ReSPECT forms and 40% of CPR occurred within 30 minutes of patient arrival.

Conclusion
Hospital A performed CPR on more patients with prior DNACPRs compared to hospital B. Occasionally, these DNACPRs were on the GP portal but were not easily accessible in the hospital setting due to the hospital’s paper-based notes system. Both sites performed CPR on a similar proportion of patients within 30 minutes of admission. This highlights the importance of prompt decisions, communication and the need for community discussion with documentation that is easily accessible across healthcare settings.
2279 Experiences of healthcare staff in an acute hospital-nursing home collaboration: a quantitative study
Authors: Ong CY , Liew YH , Lim XYS , Lee MHJ 
Published: August 2024

Abstract

Introduction
We implemented an acute hospital-nursing home collaborative pilot in two nursing homes with an objective to reduce emergency department visit and inpatient hospitalisation among nursing home residents. We aim to study the experiences of the healthcare staffs from the two nursing homes.

Method
Focus group discussions using semi structured interview guide were conducted on 26 nursing home staffs who have had experience in using the collaboration intervention. Transcripts were analysed using qualitative interview analysis.

Results
Five main domains were explored: knowledge and understanding; service satisfaction; challenges; enablers; and service improvements. Most of the ground staffs had incomplete grasp of the purpose and logic of the collaboration. However, the consensus obtained were that they felt reassured knowing they could consult hospital providers easily without activating emergency services immediately. Nursing home staffs also acknowledged having equipped themselves with skills to identify residents who required escalation of care. Interventions used such as NEWS assessment tool, hospital transfer forms and teleconsultation portal were found to be easy to use. Among the challenges faced on the ground were pressure by next-of-kins, nursing staffs’ lack of confidence, additional tasks of filling up pre-conveyance information. One of the key enablers is the motivation of staffs to improve patient care at nursing home. Increasing staffing, continuous training, and skills training were among aspects suggested for collaboration improvement.

Conclusion
Healthcare providers in nursing home faced adaptation issues during the initial pilot of the collaboration; nevertheless, they were in agreement that the collaboration is helpful for better patient care.
2283 Early supported discharge for fragility fractures -collaborative working to deliver responsive high quality patient-centred care
Authors: Davies EK , Beynon-Howells CJ , Burgess AJ , Mehta A , Ng K , Davies EA 
Published: August 2024

Abstract

Introduction
During 2022, non-femoral fractures that didn’t require operative management had 30 days median inpatient length of stay (LOS) at SBUHB. Femoral fracture patients &gt;65 years had LOS 36 days (GIRFT average 19 days), with 720 admissions. High local incidence is believed to be contributed by historical failures to identify and treat non-femoral fragility fractures. A new service was created from a collective effort to do better for our patients and prevent avoidable harm by breaking down barriers between services and promoting effective collaborative working.

Methods
A collaboration between the following key services was formed:-.
1. Older Persons Assessment Service (OPAS) -identify fragility fractures presenting to ED 2. Orthogeriatrics -identify suitable femoral fracture patients.
3. Physiotherapy -early assessment and transfer to reablement into the community.
4. Virtual Wards –ongoing CGA and reablement in the community.
Additional resource was secured to provide short-term bridging of care and community therapy input. Data was prospectively collected and included demographics, site of fracture, referrer and LOS.

Results
From March 2023, the service identified 457 patients, 312 (68.7%) Female, median age 86 years. 157 (34.6%) patients had a femoral fracture and 300 (65.4%) were non-femoral fragility fractures, majority identified by OPAS, with 206 (68.7%) being discharged same day. Overall, admission was avoided in 207 (45.3%) patients and 247 (54.6%) had an early discharge/reduced LOS with 3(0.1%) re-admissions avoided. The mean LOS on discharge is 6.6 days with a calculated monthly bed saving of 13.9 days across the service.

Conclusion
Collaborative working has created an early supported discharge pathway. Femoral fracture patients are discharged earlier, some 3 days post-op, with the necessary support to continue reablement at home. Fragility fractures are identified at the front door and offered same-day discharge with ongoing comprehensive geriatric assessment and reablement within the virtual wards with positive feedback from patients and their families.
2306 Bone health after hip fracture; does introducing a 10-day vitamin D loading regime increase use of inpatient intravenous zoledro
Authors: Devlin R , Alio Z , Brown M , Chalmers K , Rashid A 
Published: August 2024

Abstract

Background
Patients who experience a hip fracture have a high re-fracture risk. Prompt initiation of anti-osteoporosis treatment is therefore vital. Oral bisphosphonates are less well tolerated in some older people resulting in poor adherence. A single dose of IV zoledronate however, can be effective for up to 3 years and is shown to reduce fracture rate by 35% (Gregson, Age and Ageing, Vol 51, 2022).

Aim
To increase use of IV zoledronate post hip fracture in Salford Royal Hospital Local barriers: a trust guideline advising a 7-week vitamin D loading regime means inpatient IV zoledronate post hip fracture is limited. Waiting time for outpatient parental therapy is &gt;6 months.

Intervention
A new trust wide guideline was written, approving rapid vitamin D loading over 10 days post fragility fracture to promote IV zoledronate use.

Methods
Retrospective analysis of case notes for 100 patients admitted with hip fracture at baseline (August 2021) and after the intervention (August 2023). We recorded FRAX recommendation, bone health plan on discharge and osteoporosis treatment implemented.

Results
There was an increase in inpatient zoledronate use to 16% (5% at baseline). Oral bisphosphonate use reduced to 10% (28%). There was 98% adherence to the new rapid vitamin D loading regime. In cycle 2, 6% of patients did not receive planned IV zoledronate as discharged before vitamin D loading completion. 2% did not receive planned IV zoledronate despite vitamin D loading complete.

Conclusions
Rapid vitamin D loading allowed more patients to receive inpatient IV zoledronate post hip fracture. There is scope to increase this further. Future plans include adding ‘date for IV zoledronate’ to the electronic notes template and including bone health in the pre-weekend check list to minimise delay in IV zoledronate administration.
2320 DNAR: all or nothing: impact of education sessions Re-audit
Authors: Ramjohn J , Kelly J , Abdalla A , Hamad A , Carvalho J , Gibbons C , Quigley L , Finan K 
Published: August 2024

Abstract

Introduction
Do Not Attempt Resuscitation (DNAR) orders are implemented to obviate inappropriate Cardio-Pulmonary Resuscitation (CPR) in patients with low chances of survival post-CPR. However, ambiguity regarding ceilings of care for patients with a DNAR order can arise. This re-audit aimed to review DNAR and ceilings of care documentation according to national Irish Health Service Executive (HSE) guidelines after education sessions in a Model 3 Hospital.

Methods
A point-prevalence chart review of thirty-one adult medical inpatients with a DNAR order was conducted after two education sessions were held for Non-Consultant Hospital Doctors (NCHDs) and Consultants.

Results
Of all thirty-one charts, 35% documented DNAR status in the medical notes, with 32% documenting the reasoning for DNAR status, both unchanged from the first audit cycle. There was an increase in documentation of patient discussion (61% versus 45%) and reasons if this was excluded (66% versus 41%). There was no change in documentation of patient relatives’ discussion (48%) but there was an increase in the reasons if this was excluded (25% versus 18%). There was an overall increase in ceilings of care documentation for ICU admission (three-fold increase), intubation (two-fold increase), inotropic support, and comfort measures, but rates of documentation were still less than 15%.

Discussion
This audit elucidates the efficacy of education sessions in improving DNAR documentation adherence. Recent studies have highlighted uncertainty among NCHDs regarding treatment escalation in acutely unwell patients in the absence of adequately filled DNAR orders and clear documentation of ceilings of care. We posit the introduction of a Ceilings of Care document, akin to the United Kingdom’s Medical Advance Plan.

Conclusion
Accurate recording of DNAR status and ceilings of care is essential for quality care and treatment escalation. While simple education strategies have proven beneficial in enhancing compliance, additional efforts are needed to enhance ceilings of care documentation.
2269 Preventing frailty crises: improving the care of frail patients in an acute hospital Ward setting
Authors: Dhaliwal TK , Teng RSY , Tan-Pantano RT , Oo TD , Barrera VC , Espelata WDV , Teoh SN , Semeniano G , Li F , Conroy S , Rosario BH 
Published: August 2024

Abstract

Introduction
Frailty is common in hospitalised older patients and hospitalisation can lead to negative outcomes. Our study aimed to provide insights into current decision-making processes on treatment, care and discharge by clinical teams.

Methods
We conducted a prospective cohort study in frail older patients ≥65 years old admitted to acute medical and surgical wards. Clinical Frailty Scale ≥5 was used to identify frail patients and process mapping was undertaken to identify common themes, trajectories and potentially modifiable factors. We followed patient journeys from admission to discharge and examined factors contributing to longer hospitalisation. We documented existing processes, environmental, system and clinical factors influencing patient care. Comprehensive geriatric assessments identified underlying geriatric syndromes and where gaps in management were identified, we recommended frailty interventions.

Results
Fifteen patients provided informed consent, of whom 73% were female and average age 80 years, ranging 69–95 years. 67% were frail (CFS 5–6) and 33% were severely frail (CFS 7–9). Most patients were sarcopenic with a SARC-F score of ≥4 and had functional and gait impairment. 60% were underweight (BMI &lt;22). Process mapping revealed gaps in frailty-focused care and included delayed transfer to acute wards, delayed investigations, and multiple unidentified geriatric syndromes which were prevalent in this cohort. Patients fell into three broad groups, short (1–6 days), intermediate (7–14 days), or long (&gt;14 days) length of stay and delays in discharge-planning were common, mean of 4.17 days, as were delays in identification of a caregiver. Recommendations for community support services were provided to &gt;50% patients.

Conclusion
Our study shows that mapping the frail patient’s journey can identify gaps in existing processes and opportunities for improvement and collaboration. Integrating geriatric care into general wards could improve patient outcomes. We aim to use this work to guide frailty-attuned care for hospitalised older patients.
2271 Older trauma in the emergency department
Authors: Tometzki B , Harbinson C , Hammond J , Vaughn C 
Published: August 2024

Abstract

Aim
Improve the care of patients aged 65+ presenting with trauma to the emergency department by ensuring earlier senior reviews (ST4+) and consideration of trauma calls and appropriate imaging.

Method
Staff survey to assess awareness of older trauma and its management. Data analysis and collection followed by use of PDSA cycles to implement change. Teaching session on primary survey assessment and management of older trauma. Development of older trauma standard operating procedure.

Results
Improvement was seen in both primary outcomes over a period of 8 months. Documentation of primary survey improved from 30% from the initial 5 weeks to 52% over the final 5 weeks on average. Senior doctor review or discussion improved from 30% average in the first 5 weeks to 80% averaged across the final 5 weeks. There was no evidence of effect on waiting times in the emergency department for these patients.

Conclusion
This quality improvement initiative has positively impacted the early assessment of older trauma patients, aiming to mitigate the likelihood of missed injuries and adverse outcomes. While we haven’t formally assessed more complex outcome data, a notable achievement is the initiation of a cultural shift among our frontline medical and nursing staff. This shift involves approaching older trauma patients with a heightened index of suspicion. Among the interventions, the most straightforward and reproducible was the implementation of regular educational emails. We anticipate continued progress and hope that this poster serves as inspiration for other departments. Encouraging a review of how they assess and treat this expanding cohort of vulnerable, complex, and potentially critically ill patients. Unfortunately, it is not uncommon that for our growing elderly population, a trip and fall can lead to fatal consequences. We aspire for this work to contribute towards broader efforts in changing that narrative.
2329 A quality improvement project to improve bone health plan in trauma and orthopaedic discharge summaries
Authors: Perera H , Cannon A 
Published: August 2024

Abstract

Introduction
In 2022, 293 hip fractures had been admitted to the Bristol Royal Infirmary. As recommended by National Osteoporosis Guideline Group (NOGG) intravenous zoledronate is the first line treatment option following a hip fracture.

Aims
We wanted to improve bone health summaries on discharge summaries for the benefit of the General practitioner (GP), Fracture liaison service and patient.

Results
We used our local National Hip Fracture database to identify the patients who had had a fractured hip in September 2023. We then introduced our changes as part of the PDSA cycle. The change was copying and pasting a blank bone health paragraph into every discharge summary on day 1 of the patient’s admission to make it easier for the Trauma and Orthopaedic (T&O) junior doctor completing the discharge summary pre discharge. We then used an excel spreadsheet to collect results in September and October 2023 and analyse them and display them using pie charts. In September, 28.3% of discharge summaries did not have a bone health plan, compared to 25% in October. Not mentioning of Vitamin D levels in discharge summaries has increased from 57.1% to 59.4%. Mentioning of administration of inpatient zoledronic acid post fracture decreased from 32.1% to 25%.

Conclusion
Despite the intervention, the bone health plans are poorly communicated to the GP and the Fracture Liaison service, which leads to delay in administering bone health medication in a timely manner to prevent a second fracture.

Next step
Teaching Session with the T&O juniors to find out if they think it’s a good idea and discuss why they have not found the current standardised paragraph helpful. Then we can work together to make a further change (s) and start another PDSA cycle.

References
National Osteoporosis Guideline Group.UK (NOGG),2021.