bluuebunny/crossref_metadata_2025_split huggingface dataset:
699 EMBEDDING A FRAILTY TEAM AND UNIT INTO WYTHENSHAWE HOSPITAL’S EMERGENCY DEPARTMENT
Authors: Bruce S S , Saunders D , Mallouppa E 
Published: March 2022

Abstract

Introduction
Evaluation of Wythenshawe Hospital’s Acute Frailty Service in January–June 2019 demonstrated slow referrals times and poor identification of frail patients due to inaccurate Clinical Frailty Scoring (CFS) at emergency department triage. This project presents the results of ongoing quality assessment of our service between June 2019–January 2021, following two quality improvement (QI) interventions.
Aims: To evaluate our service’s ability to deliver early identification and intervention for complex frail patients via Complex Geriatric Assessment (CGA), as set out in National and Regional Frailty standards.(1,2). -To improve and maintain better outcomes for patients accessing our frailty service.

Method
Intervention1 (July’19): Specialist frailty nurses relocated to ED. Dedicated frailty clinical fellows and Consultant geriatrician input 0900–1700 weekdays. Intervention2 (Sep’20): Short-stay frailty unit opened. Junior clinical fellow cover increased (0900–1900 weekdays and 0900–1700 weekends). 299 patients seen at intervals between Jun’19-Jan’21 analysed using electronic records and completed CGA proformas.

Results
Pre-intervention Intervention1 Intervention2 June’19(n = 22) July’19(n = 198) Nov’19(n = 25) Sep’20(n = 26) Jan’21(n = 28) Time from triage-to-CGA (mins) (CI 95%)* 372.0 ± 178.2 56.0 83.4 ± 31.0 72.9 ± 35.7 48.4 ± 20.0 Discharge(%): Same day 22.7 39.4 21.7 36.0 25.0 &lt; 72 hr(cumulative) 72.7 63.6 47.8 68.0 57.1 Ave. length of stay(days)(CI95%) 10.4 ± 5.9 20.6 20.0 ± 8.7 7.1 ± 3.4 5.4 ± 2.1 Readmission &lt;30 days(%) 30.0 9.0 17.4 12.5 25.0 CGA Quality(%) CFS completion 100 96.0100 89.3 ReSPECT discussion 29.3 64.0 61.5 67.9 Full medication review 46.5 96.0 80.8 89.3 Therapy assessment 85.5 92.0 92.3 89.3 *patients triaged between 0800–1700.

Conclusion
Since Intervention1, Wythenshawe frailty service has sustained a reduction in triage-to-CGA time, maintained high percentages of same-day and &lt; 72 hr discharges, and sustained high rates of CFS completion and therapy assessments. Following intervention2, average length of stay reduced. Increased readmission rates in Jan’21 were impacted by COVID-19. Additional interventions targeted at reducing readmission rates and increasing ReSPECT discussions should be implemented. 1. Greater Manchester Frailty Collaborative and Network, 2019. 2. Same-day acute frailty service, NHS improvement, 2019.
706 IMPROVING PRESCRIPTION OF PARKINSON’S DISEASE MEDICATIONS FOR PATIENTS ON ELDERLY CARE WARDS AT ROYAL STOKE UNIVERSITY HOSPITAL
Authors: Alonge O T , Sultana N , Aung Y T 
Published: March 2022

Abstract

Introduction
Patients with Parkinson’s disease (PD) are commonly admitted into hospital with various acute medical conditions. Inaccurate prescription can result in adverse effects, increased hospital stay, and increased morbidity and mortality. We present a QIP conducted to improve PD medication prescription pattern among doctors and medication delivery from the nursing staff.

Method
In PDSA 1, we conducted a survey among doctors and nurses to assess their initial knowledge on PD medications. A baseline review of PD prescriptions on our Frail Elderly Assessment Unit (FEAU) was conducted. Our interventions include Introduction: of PD medication alert sticker attached to drug charts and recorded drug chart when they are taken off the wards. In PDSA 2, repeat survey was carried on Elderly care wards. We also reviewed PD prescriptions over a 2-week period on Elderly care wards.

Results
During the surveys, there were 55 respondents in PDSA 1 and 51 respondents in PDSA 2. The percentage of those who feel PD medications are critical medications remain similar in both cycles (98%). There was an improvement in the awareness of PD stickers from 44% to 83%. Those who feel PD alert stickers are appropriate improved from 93% to 100%. Respondents who chose all included appropriate PD medication sources for improving prescription pattern improved from 38% to 62%. There were 8 prescriptions during PDSA 1 and 21 prescriptions during PDSA 2. The use of PD stickers improved from 0% to 76%. The numbers of PD medications prescribed appropriately improved from 50% to 65%.

Conclusion
An improvement in prescription pattern was demonstrated, as we hope to improve patient safety and increase awareness across the trust. Our recommendations include use of PD medication alert sticker and recorded drug chart. We discussed our plans in Medicine Governance meeting, departmental newsletter, and presented in departmental audit meeting.
754 DEVELOPING A FRAILTY SERVICE IN ROYAL BOLTON HOSPITAL
Authors: Connolly A , Kallat A , Cairns M , Oates R 
Published: March 2022

Abstract

Introduction
Bolton NHS Trust has a busy Emergency Department (ED) in the North West. 21% of attendances are patients aged over 65. Early specialist input is recognised for frail older adults. The goal of this quality improvement project was to readdress the admission/discharge bias and to improve the quality of care for older patients in ED. A referral pathway would be implemented, and frailty team embedded into ED.

Methods
Data was collected from November 2018 to January 2020. The Frailty service underwent multiple quality improvement plans using PDSA cycles. Absence of documentation of the Clinical Frailty Score (CFS) lead to inadequate identification of frailty in ED. Frailty ACPs were based in ED to develop inter-disciplinary working whilst delivering education programmes to staff. In conjunction, Consultant-led sessions were delivered to ED trainees. This intervention was assessed by auditing CFS within patient electronic notes. Subsequent PDSA cycles resulted in CFS posters displayed in ED, in conjunction with a referral pathway to identify suitable patients. CFS scores became embedded in electronic patient records. Geriatricians reviewed directly into ED. Interventions were evaluated.

Results
Documentation of CFS increased by 20%. Referrals increased from 0 in November 2018 to 147 in December 2020. In December 2020, 52% of the patients assessed by the Frailty team were discharged, 46% of those had been referred to medicine. During the study period, the referral criteria was unreliably followed. Often referrals followed informal discussions rather than the criteria pathway. Inclusion criteria was restrictive. Education sessions were well received.

Conclusion
Basing the frailty team into ED encouraged documentation and recognition of CFS. Repeated education sessions are required due to staff turnover. Geriatrician review within ED reduced admissions to medical beds. The referral pathway has been adapted and extended to Community partners. This intervention is ongoing and will require evaluation.
769 IMPROVING THE DIAGNOSIS AND MANAGEMENT OF PATIENTS WITH COMMUNITY AND HOSPITAL ACQUIRED PNEUMONIA WITHIN ELDERLY CARE
Authors: Hoff Cv't , Chopra T , Chatterjee A 
Published: March 2022

Abstract

Introduction
In 2017 pneumonia was the most cited cause of death in elderly care at our hospital, and in 2019, we were shown to be an outlier in the incidence of hospital acquired pneumonia (HAP). Therefore, accurate diagnosis and management of pneumonia is paramount and an area for improvement in our trust. From 2017–20 we focussed on the care of elderly patients with pneumonia, aiming to improve the diagnosis and subsequent management plans.

Methods
Notes were reviewed retrospectively, examining patient notes, EPR data, radiological imaging and pathology results. We had 3 interventions across our project using teaching, posters, screensavers, and involvement of the wider MDT. HAP nursing champions were appointed, and new guidelines were published.

Results
Poor diagnostic accuracy of pneumonia was a recurrent problem. In 2017–18, focus to improve diagnosis rested on improved use of baseline investigations. By early 2019, following interventions, 75% of diagnoses were correct for community acquired pneumonia (CAP), despite ongoing poor use of investigations. Conversely, HAP patients had increased investigations but no improvement in diagnosis. Over winter 2019/20, 65% of patients had an inaccurate diagnosis of HAP. The most common reasons for misdiagnosis related to interpretation of chest x-rays and timing of diagnosis. 71% of patients misdiagnosed with HAP received antibiotics which were unlikely to be effective.

Conclusion
Improvements were made in the care of patients with both HAP and CAP. Simple interventions such as teaching, screensavers and posters affect decision-making and can improve patient outcomes. Diagnostic accuracy of both CAP and HAP can be a challenge—there were specific areas that were addressed effectively via teaching. To improve sustainability, future success of this project lies with continuous education and training of staff. A steering group will review the whole project and aim to sustain patient outcomes by digital transformation.
783 ADVANCE CARE PLANNING IN A LARGE TEACHING HOSPITAL EMERGING FROM THE COVID-19 PANDEMIC: A QUALITY IMPROVEMENT PROJECT
Authors: Holdsworth E , Ryall R , Greenwood E 
Published: March 2022

Abstract

Background
Advance care planning (ACP) is an ongoing conversation where healthcare professionals explore patients’ and families’ wishes in order to act within their best interests. The COVID19 pandemic continues to highlight the importance of timely ACP, namely while our patients have capacity. We noted that despite advancing age, accumulating co-morbidities and high clinical frailty scores (CFS); ACP discussions were not taking place within our elderly department. We aimed to increase ACP conversations and ensure documentation on ReSPECT forms to allow continuity within primary care.

Methods
10 patients per ward were randomly selected. 69 patients met inclusion criteria (over 65 with CFS ≥5 or any patient with dementia). We reviewed electronic and paper records and defined evidence of ACP as ReSPECT form including preferred place of death (PPoD), or discussion with patient or relative in medical notes. We randomly selected a pilot ward and applied interventions over 4 weeks: • Small group teaching to junior doctors • Visiting ward MDTs to identify appropriate patients for ACP • Presenting baseline data to geriatricians • Visual aids from the palliative care team and prompt sheets for doctors.

Results
Prior to our interventions, 22% of our sample had evidence of advance care planning, 33% of discussions documented on ReSPECT form. Following our intervention period we reviewed medical notes on our pilot ward. 58% patients now had evidence of ACP, with 66% documented on a ReSPECT form.

Conclusion
We achieved a significant increase in advance care planning within our elderly medicine department, and are therefore better equipped to provide personalised care alongside our patients’ wishes and values. Next steps: • Expanding teaching across the multi-disciplinary team • ACP ‘champions’ to highlight appropriate patients • Expansion of initial interventions across the department We hope to embed and maintain this change through education, training and inspiring others.
794 STANDARDISED SOCIAL HISTORY DOCUMENTATION IN MEDICAL CLERKING IMPROVES IDENTIFICATION OF FRAILTY
Authors: McGinlay A , Munang L 
Published: March 2022

Abstract

Background
Thorough social history is a crucial component of a medical admission. Understanding a patient’s functional status enables better assessment of their Frailty and better decisions about aims of treatment, rehabilitation, appropriate escalation and ceilings of care.

Introduction
The Medical Unit at St John’s Hospital Livingston, Scotland admits approximately 11,280 patients per year, of whom 55% are aged ≥65 years. Following a medical clerk-in, all admissions aged ≥65 years are screened for Frailty by a dedicated Frailty Nursing team using the Clinical Frailty Score (CFS) based on information in their electronic casenotes.

Methods
We assessed the quality of social history documentation and the accuracy of CFS in 202 medical admissions ≥65 years clerked in by medical staff over a 2 week period from 14th to 31st December 2020. Patients at end of life and those reviewed by the Frailty Advanced Nurse Practitioner prior to medical clerk-in were excluded. 3 months later this was repeated for 188 medical admissions from 12th–26th March 2021 following interventions below. Interventions An education session was delivered to trainee doctors and consultants at the Medical Unit Meeting. A pre-populated proforma was added to the electronic medical clerking document containing these prompts • Accommodation • Mobility/use of aids • Activities of daily living • Support family, district nurses • Cognition A dedicated field for Clinical Frailty Score was also added.

Results
Following intervention, documentation of social history and CFS increased from 22% to 35%. The pre-populated proforma was used in 21% of patients. In these patients, 95% had all areas of social history documented enabling accurate classification of CFS.

Conclusion
Using the pre-populated proforma significantly improves social history documentation and accuracy of CFS scoring. A change of culture is required particularly amongst junior doctors on the importance of this information, so we can deliver better patient-centred care.
659 PATIENT PERSPECTIVES OF RECOVERY AFTER HIP FRACTURE: A SYSTEMATIC REVIEW AND QUALITATIVE SYNTHESIS
Authors: Beer N , Riffat A , Volkmer B , Wyatt D , Lambe K 
Published: March 2022

Abstract

Background
Recovery is multidimensional highlighted by a wealth of qualitative evidence published on patient perspectives of recovery after hip fracture. The purpose of the current review is to synthesize this evidence of patients’ perspectives of recovery after hip fracture across the care continuum.

Methods
A systematic search was conducted, focusing on qualitative data from hip fracture patients. Two authors independently screened title and abstracts, full texts, completed extraction, and quality appraisal. Themes for this review were generated using a thematic synthesis of data from original studies.

Results
Fourteen qualitative studies were included in this review. The overall quality of included studies was high. We identified four review themes: defining recovery, feelings of vulnerability, driving recovery, and reliance on support. Patients considered recovery as a return to prefracture activities or ‘normal’ enabling independence. Feelings of vulnerability were observed for patients irrespective of the time since hip fracture and only diminished when recovery of function and activities enabled participation in valued activities e.g. outdoor mobility. Participants expressed a desire to actively engage in recovery with realistic expectations and benefits of meaningful feedback reported. Reliance on healthcare support varied by time since fracture with patients highlighting a greater reliance on professional support in the early versus late stages of recovery. Reliance on social support persisted until recovery was perceived to have been achieved and was highlighted more for participants who were living alone.

Conclusion
Patient perspectives of recovery enhance previous understanding of recovery domains. Patient perspectives highlighted hip fracture as a major life event which requires health professional and social support to overcome feelings of vulnerability and enable active engagement in recovery. Future research should investigate the recovery perspective of patients with cognitive impairment, and further consider perspectives on recovery from carers.
705 CHARACTERISING OLDER ADULTS’ RISK OF HARM FROM BLOOD-PRESSURE LOWERING MEDICATIONS: A SUB-ANALYSIS FROM THE PRIME STUDY
Authors: Hussain A S , Ali K , Parekh N , Stevenson J M , Davies J G , Bremner S , Rajkumar C 
Published: March 2022

Abstract

Introduction
Hypertension is a major risk factor for cardiovascular disease and death. Randomised trials in older adults with relatively few co-morbidities recommend treatment of their hypertension [1]. However, blood-pressure lowering medications increase the risk of medication-related harm (MRH) from adverse drug reactions (ADRs), non-adherence, medication errors and drug–drug interactions. We aimed to identify characteristics associated with MRH in older people on blood-pressure lowering medications.

Method
The PRIME (prospective study to develop a model to stratify the risk of MRH in hospitalized elderly patients in the UK) study investigating the incidence and cost of MRH in 1280 older people in Southern England [2]. Adults ≥65 years were recruited from five teaching hospitals at hospital discharge and followed up for 8-weeks. Telephone interviews with study participants, review of primary care records and hospital readmissions were undertaken to identify MRH. PRIME study participants taking blood-pressure lowering medications, as defined by National Institute for Health and Care Excellence hypertension guidelines [3], were included in this analysis.

Results
Sixty-six percent of the PRIME cohort (n = 841) were taking blood-pressure lowering medications. Patients on four blood-pressure lowering medications were five times more likely to experience MRH compared to those taking just one medication (OR 4.96; 95%CI 1.63-15.13;p = 0.01). Most harm events were serious (80%,n = 123), requiring dose change or treatment cessation. Most MRH cases were potentially preventable (49%,n = 75).

Conclusion
MRH from blood-pressure lowering medication in older people is common, serious, and potentially preventable. Decisions around maximising cardiovascular risk reduction must be carefully considered in the context of MRH from blood-pressure lowering medications.

References
1. Sheppard JP, Lown M, Burt J et al. Generalizability of blood pressure lowering trials to older patients: cross-sectional analysis. J Am Geriatr Soc 2020; 68: 2508–15.
2. Parekh N, Ali K, Stevenson JM et al. Incidence and cost of medication harm in older adults following hospital discharge: a multicentre prospective study in the UK. Br J Clin Pharmacol 2018; 84: 1789–97.
3. National Institute for Health and Care Excellence (2019). Available at https://www.nice.org.uk/guidance/ng136. Accessed 27/11/2020.
736 REAL-TIME MOBILITY DATA FROM WEARABLE DEVICES PREDICTING FALLS RISK IN OLDER ADULTS
Authors: Hewage K , Lee S , Fosker S , Hardcastle T , Ali K 
Published: March 2022

Abstract

Introduction
Falls are a common cause of injuries in people over 65 years, usually resulting in life-threatening or life-altering sequalae for affected individuals. Falls risk assessment typically requires a face-to-face evaluation delivered by a trained professional in a clinical setting, thus limiting their application for many older people with falls. Therefore, there is a need for a remote monitoring system (RMS) that captures mobility data to assess comprehensively an older individual’s true falls risk undertaking their everyday activities in their usual environment.

Methods
A pilot study was conducted with 16 participants over 65 years classified as high (n = 9) or low falls risk (n = 7) based on their fall’s history. A RMS was developed, which combines inertial measurement unit (IMU) data from a wearable device and online real-time Machine Learning (ML) to generate a two-stage fall risk assessment. In stage one, a ML activity motion classifier identified raw IMU data from participants as either, walking, resting or transitional movements (turning or sitting to standing). In stage two, previously classified motion segments were analysed by a ML fall-risk classifier, providing an objective risk assessment based on gait characteristics during everyday motion. Falls incidence was recorded prospectively at one year follow-up.

Results
The motion classifier achieved an 94.8% accuracy in differentiating between resting, walking and transitional movements. The fall risk classifier initially trained with retrospective fall history data achieved an 87.5% accuracy with 88.9% sensitivity and specificity, which is comparable to other accurate classifiers in published literature. The fall risk classifier retrained with prospective one year follow-up data achieved a 73% accuracy which was superior to the 67% accuracy of the Timed Up and Go test for falls prediction.

Conclusion
Our study shows the potential of a machine-learning remote monitoring system using information from mobility data to classify an older person’s falls’ risk.
805 UPPER LIMB FRACTURE PATHWAYS IN FRAILTY ENABLE EARLIER RETURN TO FUNCTION WITH ASSOCIATED REDUCED LENGTH OF HOSPITAL STAY
Authors: Shaw L , Maggs T , Braude P , Shipway D , Srivastava S , Kelly M 
Published: March 2022

Abstract

Introduction
Upper limb fractures are the second most common fracture requiring admission to hospital after hip fracture [Jennison, 2019]. At 1-year 20.5% have died, compared to 29.5% in hip fracture [Wiedl, 2021]. Local Problems: At North Bristol Trust most patients with upper limb fractures and a Clinical Frailty Score ≥ 5 are managed non-operatively on medical wards. Local service evaluation identified a long length of stay of 23 days. Case note review revealed: • Delayed transfers of care (DTOCs) had been managed non-weight bearing in slings for 4–6 weeks. • Non-weight bearing status resulted in DTOC due to declined access to social care and rehabilitation due to perceived health needs. • A high rate of hospital-acquired complications and failure to rehabilitate. • Breakdown in interdisciplinary communication and ownership across the pathway.

Methods
A multidisciplinary QI project was commenced. Using local data through business analytics, clinician and patient feedback, a new Trust guideline was developed for older people with frailty and upper limb fractures. Data collected determined average length of stay before and after implementation of the service change. A standard process control chart was created monitoring the effect of the changes in the pathway. The multidisciplinary team met regularly to make alterations during implementation. The resulting intervention included: • Removal of functional restrictions; allow free use of limb as comfort permits. • Simplified slings and minimised light weight casts. • Proactive integration of orthopaedic plan into CGA documentation. • Proactive interdisciplinary communication across pathways. • Patient information leaflets.

Results
Pre-intervention average length of stay was 23 days. Post-intervention was 14 days.

Conclusion
Proactive, structured management of upper limb fractures in people with frailty is associated with significant reduction in acute hospital length of stay. Next steps include a business case for a frailty trauma specialist therapist embedded into medicine.