bluuebunny/crossref_metadata_2025_split huggingface dataset:
1660 QUALITY IMPROVEMENT FOCUSSED ON IDENTIFICATION AND MANAGEMENT OF DELIRIUM IN OLDER SURGICAL PATIENTS
Authors: Millington K , Baguneid C L , Pattinson J , Ford H , Evans B , Gordon A L 
Published: July 2023

Abstract

Background
This Quality Improvement project was undertaken at University Hospitals of Derby and Burton. The team comprised a speciality doctor and improvement fellow previously employed as an operating department practitioner (ODP). Senior sponsors comprised a consultant geriatrician and Divisional Nurse Director.

Introduction
Delirium impacts up to 40% of older hospital inpatients and is associated with mortality, institutionalisation and deconditioning. We aimed to increase diagnosis and management of delirium to reduce complications, length of stay and readmissions.

Method
An initial audit measured delirium prevalence using 4AT in patients aged &gt;65 on arrival to the Surgical Assessment Unit (SAU) and 48 hours later. A series of plan-do-study-act (PDSA) cycles then tested small-scale changes to improve delirium practice on SAU. We developed, implemented and iteratively improved 4AT and delirium sections in care plans. We developed and delivered teaching and supporting materials around the PINCHME acronym to SAU staff. 4AT and delirium care plan completion rates were monitored. Staff knowledge before and after teaching was tested.

Results
36% of 111 consecutive emergency surgical admissions audited were likely to have delirium based on 4AT. 5% were coded as having delirium and 19% had delirium documented in their notes. Average length of stay was 7, 10 and 5.3 days for the whole cohort, those with and without delirium respectively. These data convinced SAU managers of need for change. Improvements around 4AT screening were associated with a rise in average 4AT completion rate from 40% to 64%. Completion rates were highly dependent on the improvement team, rising as high as 100% after interventions but falling back between these. Knowledge scores improved from 43% to 92% following teaching.

Conclusion
Improvements correlated with higher delirium screening and detection rates, and staff knowledge improved. Interventions were not sustained. We are now exploring delirium champions as a way of sustaining change.
1580 STRUCTURED MULTIDISCIPLINARY REVIEWS FOR CARE HOME RESIDENTS REDUCE POLYPHARMACY COST-EFFECTIVELY
Authors: Bradburn L , McNair S , Munang L A 
Published: July 2023

Abstract

Background
West Lothian has 17 care homes with 881 residents. General Practitioners (GP) undertake annual review of all residents, including medication review, with variability between practitioners.

Introduction
Multidisciplinary team (MDT) working is the cornerstone of comprehensive geriatric assessment. MDT meetings are an excellent environment for shared learning and discussion. We applied this principle to a 2-year project delivering structured MDT medication reviews of care home residents.

Methods
Funding was secured for a consultant geriatrician (0.5PA for 2 years, £6500 per year) to join the Lead GP, Integrated Care Pharmacist and care home nursing staff in setting up an MDT for each care home. Complex patients were discussed in monthly MDT meetings, focusing on medication reviews. Shared decisions were documented on primary care clinical notes and amendments made to prescriptions. Where necessary, further GP review assessed subsequent impact of medication changes. Annual cost savings were calculated based on the current Scottish Drg Tariff. Qualitative feedback was sought from all members of the MDT.

Results
43 residents from 9 Care Homes were discussed in 11 MDT meetings between Jan-Dec 2022. Average age was 83.3 years (64.9-101.3), 63.4% were females. In total 6 new medications were started, while 87 medications were stopped. The dose was increased in 5 medications but decreased in 37 medications. Total annual savings were estimated at £6657, an average of £155 per resident discussed. Feedback from all members of the MDT was positive, particularly for improving patient care and increasing knowledge and confidence in managing this frail population.

Conclusion
Structured MDT reviews ensured patients were on appropriate medications focusing on improving symptoms and quality of life, in keeping with principles of realistic medicine. The estimated annual savings exceeded the funding invested, making this intervention cost-effective. We plan to scale this up further in Year 2 of this project.
1614 DEVELOPING OUR OLDER PEOPLES LIAISON SERVICE: IS A FRAILTY NURSE LED MODEL THE WAY FORWARD?
Authors: Wells A , Campbell F , MacDonald E , Brown D , McCosh A , Saad I , McInnes C 
Published: July 2023

Abstract

Introduction
‘Older People in Hospital Standards’ (2015) identifies that Older People should have care/treatment in the most suitable settings. In University Hospital Monklands (UHM) a liaison service was provided to frail patients who needed care outside our older people’s wards (e.g. Surgical wards), led by clinicians (Consultant Geriatrician/ specialty doctor) twice weekly with support from Frailty nurses (FN). Patients were referred via multiple routes (email, letter, phone). Our aim was to develop a single point of referral, to increase capacity, be more responsive and FN led.

Methods
We developed the FN workface by recruiting advanced/ trainee advanced nurse practitioners. We developed an electronic referral and Electronic Frailty alerting in October 2022. We provided education/visual prompts about the service and embedded the referral pathway/criteria in the hospital ‘huddle’ and safety briefs. From December 2022, all patients referred were reviewed by a FN.

Results
From December 2022, the number of electronic referrals has increased by 70%. The number of patients who have a recorded clinical frailty score (CFS) has increased from 50 % to 98%. We now have a 5day service, where referrals are seen the same day by FN. We reduced the need for clinician input from 2 sessions/week to 0.5 sessions/week, allowing redistribution of workload. There has been no change in outcomes of discharge planning/rehabilitation/repatriation for patients before and after the change.

Conclusion
The number of referrals made electronically has increased – allows a more responsive service, standardises the pathway and reduces FN time in responding to phone calls/emails. This has increased the number of patients who have a CFS completed. It has released clinician time to deliver care in other parts of the system. Ongoing plans include developing this to be fully FN led and using it in planned care e.g. in preoperative admissions.
1627 DOES HAVING A CLINICAL COORDINATOR IN THE SAME DAY EMERGENCY CARE OLDER PERSON’S UNIT IMPROVE ITS EFFICIENCY?
Authors: Laud M , Penn O , Richardson H , Gould D , Mukokwayarira C , Harris J , Nair S 
Published: July 2023

Abstract

Introduction
The Same Day Emergency Care Older Person’s Unit (SDEC OPU) provides urgent holistic care, complementing acute and community services to deliver comprehensive geriatric assessment. In October 2022, we introduced a new clinical coordinator role with the aim of improving patient flow. Prior to this role existing, one clinician per day was assigned to take referrals alongside reviewing their own patients, without having an overview of the processes and outcomes of the day. The new clinical coordinator role included taking referrals, vetting patients in A&E, assigning tasks to clinicians, leading regular ‘huddles,’ reviewing results, preparing notes and discharge letters, and requesting specialty referrals. The role was introduced to reduce the waiting time of patients within the unit and to reduce waste through the Leeds Improvement Method.

Method
Data was analysed from a 13-week period both before and after the role was implemented, with the main focus being patient length of stay. 454 patients from before the clinical coordinator role was introduced, and 360 patients following its introduction were included.

Results
Mean length of stay was calculated at 5hr 11minutes before the role introduction and 4hr 45minutes afterwards. This reduction in length of stay (LOS) was statistically significant (p=0.015), with a 95% confidence interval where LOS was reduced between 8 and 43 minutes (p=0.0029). The percentage of patients discharged within 4 hours of arrival was 30.4% before the implementation and 36.7% after it. This was not statistically significant (p=0.0593). The percentage of patients discharged over 7 hours after arrival was 19.8% before the implementation and 13.3% after it. This was statistically significant (p=0.0143).

Conclusion
The introduction of a bespoke clinical coordinator role within SDEC OPU significantly reduced patients’ LOS; it has also provided leadership to the team, improved efficiency, and patient experience through the unit.
1613 IMPROVING ELECTRONIC FRAILTY ALERTING IN UNIVERSITY HOSPITAL MONKLANDS: A WHOLE SYSTEM APPROACH
Authors: McInnes C , Moultrie N , Wells A , Campbell F , Macdonald E , Tan E 
Published: July 2023

Abstract

Introduction
Older people with frailty are at risk of adverse outcomes from hospital admission. Early identification of frailty at can help reduce these. The Clinical Frailty Scale (CFS) identifies frailty, is quick to perform and can be done in acute settings. We have a well-established a Frailty Assessment Unit (FAU) which supports comprehensive geriatric assessment (CGA) for older adults with frailty in hospital. We developed direct admission pathway for frail patients direct from our emergency department (ED) to FAU and we needed to ensure that CFS was performed in the ED.

Methods
A training and education programme in CFS was delivered to ED via Frailty nurse practitioners. CFS was embedded in the ED safety briefs and daily handovers. A Frailty link nurse was identified in ED. We implemented an electronic CFS Frailty Alert (eFA) to our electronic Patient Management System.

Results
A direct admission pathway was established in March 2021 and eFA began in September 2021 (delayed due to Covid-19). The number of patients presenting to ED who have eFA added at admission has increased from 4/month to 100/month. This has allowed us to maintain 80% of patients being admitted to FAU (and therefore to GCA) &lt; 24 hours of attendance at hospital. The number of patients who have an eFA recorded in the overall service has also increased.

Conclusion
We improved the number of patients with an eFA in ED and can better identify who needs CGA. We can use eFA as a visual tool for site awareness of frailty which helps to support flow. Capability of ED /hospital teams to add eFA was increased and extended to Hospital@Home/ community teams. Finally, this has been shared across our NHSL sites.
1649 EVALUATION OF A FRAIL-TRAUMA (“FRAIL-T”) SERVICE IN A SCOTTISH MAJOR TRAUMA CENTRE
Authors: Craig H , Wright E , Capek E 
Published: July 2023

Abstract

Background
Geriatrician assessment is associated with improved clinical outcomes for seriously injured older adults. In 2021, the Queen Elizabeth University Hospital opened a dedicated Major Trauma (MT) ward for adults with significant polytrauma. Four Geriatrician sessions were introduced per week, establishing the ‘Frail-T' service. Our aim was to provide specialist review to frail trauma patients within 72 hours of admission.

Methods
All patients reviewed were prospectively added to a secure database. Patients &gt;65 years on the MT ward were screened for frailty and reviewed if Clinical Frailty Score (CFS) &gt;4. If medical issues arose in patients CFS ≤4, input was provided upon request. Reviews on Critical Care and surgical wards were provided on referral. Qualitative data collected after service implementation assessed staff satisfaction and service improvements. Our database was compared to analysis from 2019 and cross-referenced with the Scottish Trauma Audit Group (STAG) figures to estimate unmet needs.

Results
220 patients were reviewed between September 2021 and August 2022. Median age was 81. 33.2% of patients were frail. 45% received delirium management intervention. Compared to 2019, median time to Geriatrician input improved in polytrauma patients (5 to 3 days), but head and isolated chest injuries (usually on surgical/medical wards) experienced delays (6 and 5 days respectively). 332 additional patients aged &gt;65 on the STAG database were identified; Geriatrician review was recorded in 38% (n=126). Qualitative feedback deemed the service highly accessible (88%, n=15) with themes of improvement: greater service promotion and educational input.

Conclusions
Only a third of patients reviewed by the team were frail, reflecting requirement for medical expertise in trauma care. Cohorting polytrauma in a dedicated ward with proactive screening has improved time to Geriatrician review. Delays remain for isolated head and chest wall injuries. Improvement work will focus on greater identification of patients beyond the MT ward.
1652 USE OF AN AUTOMATED DIGITAL FLAG FOR IDENTIFICATION OF OLDER PEOPLE UNDERGOING EMERGENCY LAPAROTOMY
Authors: Sanda H , Wissenbach I , Davies E , Burberry D , James K 
Published: July 2023

Abstract

Introduction
In the presence of multiple co-morbidities and frailty, older people undergoing emergency laparotomy warrant higher supportive care. It is evident that geriatrician input to perioperative care plays a crucial role to improve patient experience and outcomes. Whilst we recognised the need for a surgical liaison service and increased compliance with NELA we had limited resources to give. We created an automatic email alert to enable us to see NELA patients and make the maximum use of our clinical time.

Method
An automated email alert was created in July 2022 to identify patients undergoing laparotomy based on theatre coding, we then set up filtering by age and frailty. A surgical liaison service was already established but we were able to target NELA patients from September 2022. Retrospective analysis of local data for Morriston Hospital extracted from 2022 National Emergency Laparotomy Audit allowed comparison of compliance to expected standards by the SOPAS (surgical liaison) service before and after intervention.

Results
There were 225 patients who required emergency laparotomy at Morriston hospital in 2022. 50 patients met NELA criteria of which 30% were &gt; 64 with high CFS and 70% over 80. A 3- month period (March-May) prior to the intervention and 3 months following (Sept-Nov). We showed an increased in compliance with NELA standards from under 10% to over 50% with this intervention.

Conclusion
Significant improvement of 5% to 50% compliance with NELA standards was observed after the intervention of email alert; further to this we noted an issue with the alert working through December 2022 where many patients were not seen. This corresponded with a period of increased mortality. Our aim going forward is to upscale this to align with the BGS Position Statement.
1528 IMPROVING DISCUSSION SURROUNDING RESUSCITATION IN OLDER PATIENTS ADMITTED TO HOSPITAL
Authors: Abbott E , Adams D , Ahmad F , Al-Agib S , Atkinson C , Bettridge A , Cuesta G , Pattison T , Reinoso P , Stiles J , Swe Y , Vilches-Moraga A 
Published: July 2023

Abstract

Introduction
One in three hospitalised patients die within 12 months of admission, rising to 45.6% in individuals aged 85 and older. Resuscitation is rarely successful in this patient group. Most older persons are happy to engage in discussions regarding resuscitation and patients’ and relatives’ involvement is recommended by British Geriatrics Society, General Medical Council and Royal College of Physicians. We aimed to increase the number of resuscitation and escalation of care discussions across our Ageing and Complex Medicine department to 90% by November 2022.

Method
Retrospective review of randomly selected electronic case notes for patients discharged in August 2021, November 2021, March 2022 and August 2022, and November 2022, to determine when resuscitation was discussed and, if not discussed, the reasons why. Interventions included:
1. face-to-face presentation of findings with discussion at departmental teaching,
2. distribution of posters on each ward,
3. discussion between each ward team, to review individual wards results.

Results
388 patient cases were reviewed over 5 data collection cycles. At baseline, in August 2021, 49% patients had discussion surrounding resuscitation, increasing to 69% following intervention 1 (November 2021) and 79% following intervention 2 (March 2022). Follow up in August 2022 showed this increase was not sustained, falling to 64%. After intervention 3 (Nov 2022) this rose again to 72%. August 2022 data was evaluated to identify reasons behind no discussion. The main reason was ‘good baseline’ (31.1%) with no documented reason in 48.3% cases.

Conclusion
Percentage of resuscitation discussions has fluctuated over time, improving following targeted intervention but has not yet reached 90%. The main barriers to success identified included junior doctor change-over, fast patient flow, competing ward priorities and patients/relatives lack of understanding. We hope to integrate teaching regarding resuscitation into our departmental induction, to sustain knowledge and understanding within the workforce.
1606 TREATMENT ESCALATION PLANNING: UNDERSTANDING THE SYSTEM TO ENABLE CHANGE
Authors: Stirzaker A G , Rangar D , Ajaz S K , Aston O , Batchford C , Beretta D , Coke M A , Kelly Z , Palin M , Zainal H 
Published: July 2023

Abstract

Introduction
The 2020-21 Chief Medical Officer report described Treatment Escalation Plans (TEPs) as ‘Realistic Medicine in action.’ Our aim is to increase TEP completion on the Medicine of the Elderly (MOE) wards at the Royal Infirmary of Edinburgh to &gt;90% by July 2023.

Method
Since August 2022, we collected weekly data from a single MOE ward. In October, we upscaled to include four MOE and one stroke ward. The notes of five randomly selected patients were reviewed weekly to see whether they have a TEP, and if so, which parts were completed. To further understand behaviours around TEP completion, we collected qualitative data asking doctors what the triggers and barriers were to TEP completion. 40% found the conversations challenging whereas 30% cited time and environment as barriers. We used this data to generate change ideas. For PDSA cycle 1, we developed a teaching session around TEP conversations. This is delivered regularly to all junior doctors and ANPs in the department. For PDSA 2, we allocated a weekly ward ‘TEP champion’ to highlight patients without a TEP and encourage completion.

Results
Median for TEP completion was 75% on the initial ward, 42% over the four MOE wards and 20% for the stroke ward. All patients with a TEP had their resuscitation status documented. One third of patients did not have a TEP at all. Of the two thirds of patients with a TEP, a quarter were incomplete. Sections on goals of care, communication and interventions were completed in around half.

Conclusion
This project is ongoing with future PDSAs planned to address the barriers of time and environment. PDSA 3 will test the introduction of a mobile TEP phone to enable discussions in a quieter environment. The variation in practice in MOE versus stroke is important and requires further understanding of the barriers specific to stroke.
1611 MEMORY LINK WORKER WITHIN GENERAL SURGERY: A PILOT
Authors: Skinner R , Brown K , Jardine N , Ham S , Humphry N 
Published: July 2023

Abstract

Introduction
The General Surgery directorate at Cardiff and Vale University Health Board secured funding for the appointment of a Memory Link Worker (MLW) for a 12-month pilot in the emergency stream. The aim of the MLW is to improve patient experience for those living with dementia/ cognitive impairment, or those who experience delirium whilst in hospital. In addition, the MLW role should increase awareness and completion rates of “Read About Me” (RAM).

Method
The pilot scheme started in February 2022. Eligible patients were identified by ward staff or the Perioperative care of Older People undergoing Surgery (POPS) team and referred in person or via bleep. The MLW reviewed patients, offered activities, contact families / carers and completed the RAM. MLW input continued for the duration of the admission. Objective assessment of the impact of the MLW interventions on patient wellbeing was completed through Dementia Care Mapping (DCM) – an observational tool to improve person-centred care for people living with dementia.

Results
104 patients have been reviewed to date. Average caseload of 6 patients per week. Average time spent with each patient during their admission is 5 hours 51 minutes. Two thirds of patients engage in activities offered by the MLW. DCM demonstrated a positive impact on patient well-being, mood and engagement. Very few patients were able to self-entertain in the absence of the MLW and those that did were using tools supplied by the MLW.

Conclusion
The MLW role has had a positive impact on patient experience as demonstrated by the DCM process. Further analysis of the impact of the role is underway, including feedback questionnaires from staff members and service-users, as well as re-audit of RAM completion rates. We hope this will support a business case to ensure the MLW is a substantive role in general surgery.
1621 FOUNDATION YEAR 1 DOCTORS’ (FY1S) KNOWLEDGE OF FRAILTY AND COMPREHENSIVE GERIATRIC ASSESSMENT: A COHORT SURVEY OF 31 FY1S
Authors: McStay D , Aurangzeb I , Harrison C , Bertfield D 
Published: July 2023

Abstract

Introduction
The British Geriatrics Society and NHS England recommend that patients aged 65 and over should be screened for frailty when presenting to healthcare services to facilitate early comprehensive geriatric assessment (CGA). Recognition of frailty frequently relies on assessment by FY1s. We sought to assess a) how confident FY1s are in recognising and managing frailty, b) their understanding of CGA, and c) how these change during the year.

Methods
Questionnaires (quantitative and qualitative data) were given to FY1s at induction, 6 months, and 12 months. Teaching sessions on frailty and CGA were delivered. We collated feedback on how frailty recognition and CGA knowledge had altered their assessment of older people.

Results
All FY1 Doctors completed the survey at induction. The 6 months and 12 months surveys were emailed to FY1s. The survey response rate was 100% (31/31), 68% (21/31) and 58% (18/31), respectively. At induction, 23% (7/31) reported they were “quite” or “very” confident in assessing for frailty. This increased to 71% at 6 months and 100% at 12 months. Fifty-two per cent (16/31) of FY1 Doctors were aware of a tool to assess for frailty at baseline, increasing to 100% (18/18) at 12 months. Knowledge of CGA improved less, from 48% (15/31) at baseline to 83% (15/18) at 12 months. There was no association between speciality experience and confidence levels. Feedback from FY1 doctors indicated that frailty recognition allowed identification of patients who may benefit from advanced care planning discussions and triggered early therapy input.

Conclusions
Despite BGS and NHS England recommendations, at induction, FY1s lack confidence in frailty recognition and assessment. Through experiential learning and targeted teaching this improved, not limited to those in geriatric medicine. We recommend final year medical students need increased frailty and CGA specific education to improve their confidence when assessing frail older patients.