bluuebunny/crossref_metadata_2025_split huggingface dataset:
1563 IMPROVING DOCUMENTATION OF TREATMENT ESCALATION PLANS WITHIN 72 HOURS OF ADMISSION TO EAST LOTHIAN COMMUNITY HOSPITAL
Authors: Galloway S , Farren A , Johnson R 
Published: July 2023

Abstract

Introduction
East Lothian Community Hospital (ELCH) comprises of 95 medical beds for older patients undergoing rehabilitation following acute admission or discharge planning. Ideally, transfers from acute hospitals should have Treatment Escalation Plans (TEPs) in place, however only 67% of patients had a TEP documented electronically within three days of ELCH admission. Overnight and weekend cover is provided through nurse practitioners or Hospital at Night (off-site), therefore documented individualised plans by senior decision makers in the event of clinical deterioration is vital.

Objective
95% of patients admitted to ELCH would have a provisional TEP documented electronically within 72 hours of admission by February 2023.

Methods
Using quality improvement methodology, two Plan-Do-Study-Act cycles were completed. Firstly, a questionnaire was sent to junior doctors and nurse practitioners responsible for admitting patients to understand barriers to completing TEPs. Data was collected from electronic records on admission date, first documentation of provisional TEP (by a junior doctor or nurse practitioner) and admitting ward. The first cycle of change focused on increased awareness through posters reminding clinicians to consider TEP on admission. The second cycle of change involved two education sessions, highlighting the importance of TEP and how to approach difficult conversations.

Results
28.5% of junior clinicians did not feel comfortable discussing TEPs on admission, with barriers being time constraints, level of responsibility and concern about making incorrect decisions. The first cycle (increased awareness) showed an improvement in documented provisional TEPs within 72 hours of admission from 67% to 79%. The second cycle (two education sessions) saw a further improvement to 94%.

Conclusions
Basic interventions to increase awareness and education to address concerns surrounding TEP discussions were very effective. Future cycles are planned with new junior doctors to sustain the improvement. Next steps are to clarify the role of other medical practitioners in completing provisional TEPs.
1511 IMPROVING THE IDENTIFICATION AND MANAGEMENT OF DELIRIUM AT THE FRONT DOOR
Authors: Livie V , Crowther J 
Published: July 2023

Abstract

Background
Delirium is common especially in the older adult (≥65 years) and is characterised by disturbed consciousness, cognitive function or perception. It develops acutely, often has a fluctuant course and is associated with several adverse outcomes including increased length of hospital stay, increased mortality and increased incidence of developing dementia. Delirium is under-recognised, however assessment tools such as 4AT and abbreviated mental test score (AMTS) have been developed to help clinicians assess for the presence of delirium.

Method
The “TIME” bundle developed by Healthcare Improvement Scotland helps clinicians to think about underlying triggers for delirium. Baseline data collected from a care of the elderly ward showed that 26% (5/19) of patients aged ≥65 years had a delirium assessment tool used on admission. 42% (8/19) of patients were given a diagnosis of delirium on admission. Out of the 8 patients diagnosed with delirium, only 13% (1/8) of patients was assessed for urinary retention, 50% (4/8) for pain and constipation and 25% (2/8) had blood glucose measured. Several PDSA cycles were implemented including an educational session to promote early detection and management of delirium, poster detailing 4AT assessment and “TIME” bundle and use of a 4AT sticker in the medical admission booklet.

Conclusion
The sticker was the most successful intervention as results showed 50% (13/26) of patients aged ≥65 years had a delirium assessment tool filled in on admission. For those diagnosed with delirium, assessment for urinary retention and blood glucose measurement improved to 78% (7/9), pain assessment improved to 67% (6/9) and 100% (9/9) of patients were assessed for constipation. In conclusion, this project has improved use of delirium assessment tools at the front door and when delirium is recognised, there is greater awareness of common underlying causes. Planned future cycles include a ward “delirium champion” to help with recognition and management of delirium.
1539 IMPROVING RECORDING OF THE CLINICAL FRAILTY SCALE BY PHYSIOTHERAPISTS IN OLDER PEOPLE'S MEDICINE: A QUALITY IMPROVEMENT PROJECT
Authors: Buckland C 
Published: July 2023

Abstract

Introduction
Frailty is under-recognised in hospital leading to unwarranted variation in care. National guidance recommends that all healthcare professionals can identify frailty and offer interventions to reduce risk factors for frailty. Previously, physiotherapists working in Older People’s Medicine (OPM) did not record frailty status in their clinical assessment. This quality improvement project seeks to translate and implement best practice, supporting physiotherapists to record the Clinical Frailty Scale (CFS) score within routine patient assessment, so interventions can be initiated to optimise outcomes.

Project aim
Within 3 months, to achieve a 50% increase in the number of patients with a Clinical Frailty Scale (CFS) score recorded within their physiotherapy assessment.

Methods
Plan-Do-Study-Act cycles with interventions of bespoke teaching and assessment proforma re-design were employed targeting the OPM physiotherapy team on ward 31, RVI.

Measures
The weekly number of patients with a CFS score recorded within physiotherapy assessment was collected over 13 weeks and evaluated on a run chart. Staff knowledge and skills self-assessment scores and cohort data were also recorded and described using descriptive statistics.

Results
At baseline – 0/114 (0%) physiotherapy patients had a CFS score recorded, this improved to 95/192 (49%), suggestive of effective change post interventions. Staff confidence scores also improved.

Conclusions
This project has led to improved frailty awareness and identification amongst OPM physiotherapy staff. Furthermore, these efforts are being sustained, and implemented in other areas of acute care. This work supports a collaborative approach to improving frailty care; better identification of frailty can reduce harm by informing healthcare needs, supporting patient flow, and resulting in better, safer, and more equitable care.
1569 BUILDING A HOLISTIC SERVICE FOR PATIENTS WITH PARKINSON'S DISEASE AND PSYCHIATRIC SYMPTOMS
Authors: Tullo E , Henry S 
Published: July 2023

Abstract

Introduction
Parkinson’s Disease (PD) is recognised by the motor symptoms of tremor, rigidity and bradykinesia. However, the prevalence of psychiatric symptoms such as low mood, anxiety and memory problems in PD is also common (20-80%). We integrated one clinical session per week from a Parkinson’s specialist psychiatrist (PDSP) into our existing MDT service, and aimed to evaluate the impact of this model on care for patients with PD.

Method
We initiated a series of Plan Do Study Act (PDSA) cycles to establish a referral pathway to our PDSP. Using electronic clinical records we collected data from a cohort of PD patients seen by our PDSP over 6 months to map symptoms, time to review, diagnosis, treatment and follow-up. We estimated the number of referrals to other services that did not need to be made over the same period due to access to our PDSP

Results
Fifty-one patients with PD were referred to our PDSP with the following symptom(s): memory impairment (53%), low mood (42%), hallucinations (10%), anxiety (8%) - all were seen within eight weeks. Of the 27 patients referred with memory impairment, review by our PDSP meant that 15 did not need onward referral to a separate mental health service. Of 14 patients with low mood (without memory impairment), review by our PDSP meant that 12 did not need onward referral.

Conclusion
Prior to the integration of a PDSP into our PD MDT patients with psychiatric symptoms needed to be referred to another clinical service, often with a long wait for assessment and treatment. With access to a PDSP, 51 patients were reviewed within eight weeks, and 27 did not need onward referral to another service. We do not yet have evidence as to how patient outcomes differ before and after integration of a PDSP into our team.
1595 WHAT IS THE IMPACT OF A PRE-HOSPITAL GERIATRICIAN LED TELEPHONE ‘SILVER TRIAGE’ FOR OLDER PEOPLE LIVING WITH FRAILTY?
Authors: Jones H T , Teranaka W , Wan B , Tsui A , Gross L , Hunter P , Conroy S 
Published: July 2023

Abstract

Background
The Ageing Well programme within the NHS Long Term Plan promotes person-centred care aligning with the goals of Integrated Care Systems (ICSs) in unifying health and social care aiming to increase the proportion of care to older people delivered in the community (NHS England, 2019). As most older people admitted to hospital are conveyed by ambulance services this presents a focus to reduce hospitalisation (Maynou L, Street A, Burton C, et al. Emergency Medicine Journal 2023). North Central London ICS has invested in ‘Silver Triage’ a pre-hospital telephone support scheme which sees geriatricians and emergency physicians supporting the London Ambulance Service in their clinical decision making relating to older people at the point of assessment.

Methods
Data from the first fourteen months of the scheme was analysed.

Results
Between November 2021 and January 2023 there have been 452 Silver Triage cases with 80% resulting in a decision to not convey an older person to hospital. The mode clinical frailty scale (CFS) score was 6 with no difference in conveyance rates based on CFS. Prior to triage paramedics thought hospitalisation was not needed in 44% of cases (n=72/165). Most paramedics (93%, n=154/165) found it easy to contact the team with all 176 who responded to a post triage survey answering they would use it again. Many (66%, n=108/164) felt they learnt something from the discussion, with 16% (n=27/164) reporting it changed their decision-making process.

Conclusion
Silver Triage has the potential to improve the care of older people by preventing unnecessary hospitalisation and has been well received by paramedics.
1624 IMPROVING THE QUALITY OF TEACHING WITHIN THE AGEING AND COMPLEX MEDICINE DEPARTMENT; INTRODUCING A NOVEL TEACHING PROGRAMME
Authors: Alićehajić-Bečić Ð , Rehman H , Hough S , Ali S 
Published: July 2023

Abstract

Introduction
Feedback from the National Training Survey (NTS) in 2018 showed suboptimal satisfaction levels within our department, particularly for local teaching and clinical supervision. A novel dedicated teaching and training programme was designed and implemented. National and local feedback from trainees highlights significant improvement in satisfaction levels across all domains.

Method
The new programme includes scheduled weekly teaching using a defined geriatrics curriculum; simulation sessions, improved opportunities for bedside teaching and workplace-based assessment, opportunities to present patients/interesting topics at weekly teaching, overhaul of our induction programme, support and supervision with QIPs/research including formal end of placement QIP presentation sessions. We reviewed national feedback alongside our own locally sourced feedback to quantify improvements in satisfaction levels and address further areas for improvement.

Results
Feedback from the NTS shows satisfaction within all domains has improved between 2018 and 2022. In particular, satisfaction with clinical supervision improved from 80.1 (below national average) to 88.33, satisfaction with our induction process improved from 75.19 to 88.89 (above national average) and satisfaction with local teaching improved from 70.83 to 81 (above national average). Local feedback showed that trainees are satisfied with the quantity and quality of teaching and training during their placement; 92.5% rated the quality of clinical supervision as very high or high quality, 95% felt the formal teaching was useful to their learning, and 90% would recommend an ACM placement at RAEI to their colleagues.

Conclusion(s)
Our teaching and training programme has improved the quality and quantity of learning experiences for junior doctors within our department. There are domains in which satisfaction remains suboptimal including “rota design” and “workload” however there are factors affecting these areas which are out of the control of our department and therefore may present challenges when trying to implement change.
1641 NALOXEGOL USE IN A POST-OPERATIVE GERIATRIC WARD: A FEASIBLE, COST-EFFECTIVE TREATMENT FOR OPIOID-INDUCED CONSTIPATION
Authors: van Rhee C , Ramesh P , Roth N , Chaudhuri S , Bharkhada K , Koizia L 
Published: July 2023

Abstract

Introduction
Elderly post-operative patients are susceptible to opiate-induced constipation (OIC) and many fail to open their bowels despite regular laxative prescription. Naloxegol is a gastrointestinal opiate antagonist licensed to treat OIC in patients failing laxative therapy. Naloxegol’s higher unit price than standard laxatives may present a barrier to its use by hospital pharmacies. We present a quality improvement project on the feasibility and cost-effectiveness of using of naloxegol to treat OIC in the real-world setting of a geriatric post-operative ward.

Methods
Initial Audit- Review of inpatient notes from October-November 2022 identified patients on opiates who failed laxative therapy during admission (bowels not opening for ≥3 days, despite 4 consecutive days of laxatives). Average number of bowel motions per week following failure of laxative therapy and number of laxative doses received were recorded. Total cost of laxatives was recorded for each patient. Intervention – Naloxegol was supplied to the ward for patients meeting criteria of OIC failing laxative therapy. From December 2022-January 2023, naloxegol was prescribed to these patients. Laxatives were stopped on receipt of naloxegol. Naloxegol was stopped on cessation of opiates.

Results
Baseline audit identified 63.9% patients on opiates had failed laxative therapy. Following laxative therapy failure, average number of bowel motions/week was 2.65. Average cost of laxatives per patient was £3.77. Accounting for length of admission, average cost of laxatives per day was £0.13. During the intervention period 67.2% patients on opiates failed laxative therapy. 13 patients were prescribed naloxegol. Average number of bowel motions on naloxegol was 5.1/week. Average combined cost of laxatives and naloxegol per patient was £1.93. Average combined cost of laxatives and naloxegol per day was £0.08.

Conclusions
In this small-scale quality improvement project we demonstrate that naloxegol is both clinically effective and cost-effective in treating OIC in geriatric post-operative patients failing laxative therapy.
1551 AN ANP IN DEMENTIA SERVICES AND COLLABORATIVE WORKING WITH H@H SIGNIFICANTLY IMPROVES PATIENT ACCESS TO A DIAGNOSIS OF DEMENTIA
Authors: Rowlands M , Roscrow S , Munang L , Johnston S , Rimer J 
Published: July 2023

Abstract

Introduction
Scotland’s National Dementia strategy (2017) highlights the need to improve identification and management of dementia. Hospital at Home (H@H) teams often identify undiagnosed cognitive decline as part of comprehensive geriatric assessment. A trainee ANP in dementia services was appointed in 2019 in West Lothian; before this, the average waiting time to memory clinic assessment was 6 months for a home visit, and 12 months for outpatient clinic review. Affiliated with REACT H@H, the ANP identified a significant unmet need for assessment of cognitive decline in a patient cohort referred to H@H.

Method
Baseline data from patients reviewed by the dementia ANP was collected between Sept 2021 – Feb 2022, including referrals from H@H. A new pathway was then introduced to streamline referrals with education and upskilling of the H@H team. Further data was collected between Sept 2022 – February 2023.

Results
In the first cohort, 161 patients were assessed by the Dementia ANP, of which 39 (24%) had been referred from H@H. 60 patients (37%) were seen as a home visit, and 101 (63%) in clinic. 2 (1%) of referrals were managed with advice only. 125 patients (78%) were given a diagnosis of dementia; other diagnoses included delirium, low mood and anxiety. In the second cohort, 168 patients were assessed by the Dementia ANP, 39 (23%) being referred from H@H. 94 (56%) were seen in clinic and 74 (44%) as home visits. 10 (6%) of referrals were managed with advice only. 138 (82%) were given a diagnosis of dementia. Time to diagnosis of dementia was reduced to 1 month for home assessment, and to 4 months for outpatient clinic assessment.

Conclusion
Appointment of a Dementia ANP to work alongside H@H significantly improved access to specialist services and time to diagnosis of dementia as part of comprehensive geriatric assessment.
1498 THE CGA BOARD ROUND – IMPROVING DOCUMENTATION AND COMMUNICATION FOR OLDER ADULT INPATIENTS, UNIVERSITY HOSPITAL HAIRMYRES
Authors: Watt M , Grannan R , Peacock L 
Published: July 2023

Abstract

Background
Acutely unwell hospitalised older people have better outcomes including mortality and functional status when CGA (Comprehensive Geriatric Assessment) is performed. A previous complaint, escalated to the Scottish Public Services Ombudsman, highlighted issues with CGA documentation and recording MDT discussion. This pilot project’s aim was to create a method for documenting CGA MDT plans and to embed this as routine practice for all inpatients on a Geriatrics ward.

Method
Following consultation with staff on this ward, a sticker was developed detailing status of medical and therapy input, planned discharge date and likely required support on discharge to evidence MDT discussion. This was completed weekly at the board round for each patient. The stickers were implemented over a 2-week roll-out phase, and use (and completion) of stickers were compared to a 2-week period approximately 1 month later. Feedback from ward staff was also collected via questionnaires.

Results
Initially, 98% of patients had a sticker completed (n=49/50) and 86% of all required information was documented (n=43/50). For the second round of data collection this fell to an 18% completion rate (n=7/38). Ward staff interviewed were aware of the stickers and felt they improved CGA communication (n=100%, n=8/8). Suggestions for improvement included an option to record whether families were updated, clearer options for discharge status and reasons why a patient may not have received occupational or physiotherapy.

Conclusion
The CGA board round sticker was a positively received, simple and effective intervention to improve documentation. It addressed an area which had been highlighted as requiring improvement. As expected, initial completion rates were high but rotation of staff impacted on subsequent completion rates. Establishing this as routine practice will be challenging but permanent staff present at the board round will facilitate allocation of this task and a poster highlighting this process has been displayed on the ward.
1558 THE ROLE OF COMPREHENSIVE GERIATRIC ASSESSMENT AND SHARED DECISION MAKING IN PATIENTS BEING CONSIDERED FOR ORTHOPAEDIC SURGERY
Authors: Godage P , Bell T , Hobbs H , Forsyth L , Litto E , McCluskey Mayes B , Meilak C 
Published: July 2023

Abstract

Introduction
Our perioperative service for older people undergoing surgery (POPS) commenced preoperative assessment of co-morbid and frail patients undergoing elective orthopaedic surgery in 2021. As part of the comprehensive geriatric assessment (CGA) and shared-decision-making process (SDM), we wanted to analyse the decisions our patients made around surgery and how many regretted having surgery.

Methods
Review of all orthopaedic patients seen by POPS between September 2021-December 2022.

Intervention
CGA and SDM on all patients.

Data collected
comorbidities, Clinical Frailty Scale (CFS), SDM outcome. Decision regret scale was sent out 6 months post op from August 2022.

Results
111 patients assessed. Median age 89 (range 60-97). Median CFS 4 (range 1-7). Median comorbidities 12 (range 2-22). Surgery considered: knee 43%, hip 33%, shoulder 10%, spine 6%, revision hip 5%, and revision knee 3%. 77% wanted to proceed with surgery and 13% did not after SDM. 5% were deemed not fit enough and 5% are still awaiting final decision outcomes. Decision regret data has been returned by 10/14 (71%) of patients who proceeded. None regretted their decision.

Conclusion
The majority of patients seen by POPS wish to proceed with orthopaedic surgery. However, 13% did not wish to proceed following SDM which is similar to the 14% of patients who regretted undergoing surgery in other settings1. Of those that have returned the 6-month post op questionnaires, none have regretted their decision. Understanding how optimisation and appropriate SDM impacts on the patient experience is important as frailty impacts adversely on patient reported outcomes in elective hip and knee surgery. Frail patients are also less likely to report their postoperative outcomes in national data sets compared to less frail patients2.
1. CPOC website
2. Cook et al (2022). The impact of frailty on patient reported outcomes following hip and knee arthroplasty. Age and Ageing.
1655 FRONT DOOR FRAILTY: A QUALITY IMPROVEMENT PROJECT TO REDUCE PREVENTABLE EMERGENCY ADMISSIONS FOR OLDER ADULTS
Authors: Jackson E , Millington K , Roth K , Parkinson F , Gordon A , Evans B 
Published: July 2023

Abstract

Background
Up to 17.5% of admissions for older adults with frailty may be Preventable Emergency Admissions (PEAs). PEAs are costly and expose patients to complications including deconditioning, delirium, malnutrition and nosocomial infections. Royal Derby Hospital (RDH) has 1159 beds and cares for a population of around one million. The Frailty Emergency Assessment Team (FEAT) operates within the Emergency Department (ED) and Medical Assessment Unit. FEAT is multi-disciplinary, comprising nurses, physiotherapists and occupational therapists.

Aim
To reduce the number of PEAs for older adults presenting to RDH.

Design
We integrated a Geriatrician into FEAT with the aim of reducing PEAs through early medical reviews. Suitable patients were identified through referral from ED and routine screening of the patient information system. To support consistent medical reviews and automate data collection we created an e-form embedded within the Electronic Patient Record. This captured details and outcome of medical reviews including Clinical Frailty Score (CFS), problem list, medication review and ‘Medically Stable for Discharge’ (MSFD) status.

Results
Between 7th February 2022 and 20th February 2022 68 medical reviews were collected on the e-form. 72% were assessed first by an ED clinician. 81% had a CFS of 5-7 and 7% had a CFS of 8. The most common presenting complaint was ‘fall(s)’ (25%) followed by ‘clouded consciousness’ (13%). 66% of FEAT physician reviews resulted in planned discharge from ED, 13% of which avoided an admission planned by ED. Of 68 patients reviewed 42 (62%) were MSFD. Of these 29 (69%) were discharged home, 11 (26%) were admitted to a ward to await interim beds or new care package, one (2%) patient was discharged to a care home and one (2%) to another health care facility.

Conclusion
Our intervention reduced PEAs for older adults presenting to RDH. The e-form automated data collection successfully.