BGS Spring 2021 Poster Book by Team BGS

Analgesia and Anaesthesia in Fractured Neck of Femurs (#NOF) Dr S Easby FY3, Dr J Dilley Consultant Anaesthetist Results BACKGROUND The definitive management of hip fractures is operative fixation Prompt assessment and response to pain helps speed up recovery and prevent complications Previous audits have identified poor documentation of pain scores and rate of nerve blocks

METHODS Retrospective review of 32 case notes and electronic prescribing NICE Hip Fracture Management Guideline CG124

KEY FINDINGS 1. Documentation of pain scores has improved, although occasional dubious recording of consistent zeros

This graph shows an increase in the rate of recording pain scores in all settings. Mandatory assessment of pain as part of e-observations may account for the large increase post op. 100% of patients received analgesia as per guideline

2. 41% received nerve block on admission 3. Vast majority of patients received intra-operative nerve block

TAKE-AWAY High levels of adherence to NICE guidelines for #NOF Refresher to be given to ward staff on assessment and management of pain Hip Fracture Specialist Nurse now competent in nerve blocks may increase rate on admission

There is a year on year increase in nerve blocks on admission and intra-operatively . Intraoperatively, most patients receive a fascia iliaca compartment block (FICB) with the remaining receiving a femoral nerve block. Template by Animate Your Science

The Impact of Comprehensive Geriatric Assessment on the Outcomes of Older Acute Neurosurgical Patients Dr. Lauren Soutter1; Mr. Christopher Uff2; Mr. Stefan Yordanov2; Dr. Dhanupriya Sivapathasuntharam1 Introduction: Increasing proportion of the neurosurgical caseload consists of older patients. Comprehensive geriatric assessment (CGA) is the gold standard for evaluating older patients. Orthogeriatrics and peri-operative care of older people undergoing surgery (POPS) have shown that CGA results in fewer post-operative complications in orthopaedic and vascular surgical patients. Currently, there is little evidence of the impact of CGA in neurosurgery. Aim: To investigate whether CGA for older neurosurgical patients in a London teaching hospital improves outcomes. Methods: 1. Control group = prospective data collected for all acute neurosurgical patients over the age of 65. 2. An intervention group received CGA in the form of regular geriatric consultant reviews. 3. 49 patients were recruited into each group. Results: Analysis showed that the interventional group had a significantly higher mean age and level of frailty.

Neurosurgery services should consider embedding geriatrician reviews into existing pathways.

A significant difference was found in the 2 groups in terms of diagnosis of pneumonias (p=0.05) and in hyponatremia (p .015). . No geriatrician Geriatrician P value input input Pneumonia

0.05

ACS Arrhythmia HF UTI PE Urinary ret AKI Delirium <Na >Na <K >K Sepsis

1 6 5 11 2 3 11 16 6 9 6 2 8

1 8 7 17 1 7 11 18 16 3 9 5 3

1 0.564 0.538 0.180 0.558 0.182 1 0.567 0.015 0.064 0.400 0.239 0.110

Could a decrease in sepsis in the post-intervention group be due to better diagnostic process?

Key findings

Older patients constitute a major and increasing proportion of the neurosurgical workload. More specific diagnoses were identified by patients reviewed by a geriatrician. Geriatrician reviews of older neurosurgical patients may improve outcomes such as length of stay, mortality and lead to more patients being discharged home. This is an area where more research should take place including a formal randomised controlled trial.

The 30 day mortality was lower (p=0.749) as well as inpatient mortality (P=0.39) compared to the control group, but did not reach statistical significance.

Average length of stay was 2 days shorter but did not reach statistical significance (p=0.701). Fewer patients discharged to their local hospital, with more going home directly (p=0.209).

There were more men than women - a deviation to other studies where female population predominates.

1Geriatric

department at the The Royal London Hospital

2Neurosurgery

department at The Royal London Hospital

Educational programmes for frail older people, their families, carers and health-care professionals: A Systematic Review Rachel Viggars1 Andrew Finney2 Barnabas Panayiotou3 1. Rachel VIGGARS QN, BSc (Hons), DipHE, MMedSci. Associate Director of Nursing, North Staffordshire General Practice Federation, 69-71 Stafford Street, Hanley ST1 1LS, England. Nurse Lead, Staffordshire Training Hub, GP First Ltd, Stafford Health and Wellbeing, Whitgreave Court, Stafford, ST16 3EB, England. 2. Andrew FINNEY RN, Dip, BSc, PhD.Senior Lecturer of Nursing, School of Nursing & Midwifery, Keele University, Staffordshire ST5 5BG, England. 3. Barnabas PANAYIOTOU BMedSci (Hons), BMBS, PgCertMedEduc, MD, FRCP. Honorary Senior Clinical Lecturer, Postgraduate School of Medicine, Keele University, Staffordshire ST5 5BG, England.

INTRODUCTION

The synthesis highlighted 4 prominent thematic domains that are key elements to both prevention and management of frailty for all target populations and are demonstrated in Figure 2. Frailty must be addressed within a multimorbidity approach. The evidence highlighted the importance of maintaining active living and wellbeing for older people

An increasingly older population is resulting in more people living with frailty and requiring additional health care and personal support services. The Frailty: Core Capability Framework (FCCF)1 launched recently in the UK recommends frailty education for all frail older individuals, their families, carers and health professionals. We report the findings of a Systematic Review of published reports that outline specific educational programmes for these groups.

DISCUSSION

OBJECTIVES

Educational programmes and initiatives are vital for the prevention and management of frailty and to be truly effective must include a combination of the four thematic domains; empowerment, self care, health promotion and access to educational schemes and be accessible to all target populations (Figure 2).

To identify, describe and assess the variety of interventions for frailty education To synthesise the findings of the research studies To determine key themes within educational initiatives appropriate to the target population of older people living with frailty, families / carers and HCPs

METHODS Inclusion and exclusion criteria: The Inclusion and Exclusion criteria were set according to the standard PICO domains framework (CRD, 2018) i.e. Population, Intervention, Comparison, Outcomes. MeSH headings were chosen to identify key aspects of interest in the publication. The three broad aspects of interest were Frailty, Education or Training and Study Setting.

The combination of exercise and nutritional programmes have been shown to have a positive impact on frailty status. Primary care services need to take a prominent role in promoting this. These key findings can usefully be considered within the context of the FCCF document. The papers evaluated in this review have demonstrated a practical feasibility of a wide range of different programmes together with favourable results of interventions and whilst non of the studies incorporated a large proportion of the FCCF, there is clearly scope for more comprehensive educational programmes to encompass even more of the FCCF.

Screening and selection of publications: Two reviewers performed the Identification

selection in order to reduce the risk of bias and to increase accuracy.

Counselling Motivational interviews Psychotherapy Improve self-efficacy and skills

Empowerment

Self care

Health promotion

Access to educational schemes

Included

Eligibility

Screening

Care goals setting Shared decision making Health literacy

Figure 1: PRISMA flow chart depicting the literature search, screening and selection of research papers

Data extraction and study quality appraisal: Data extraction was performed methodically across all papers using a structured data extraction form which was set up in electronic format that facilitated the comparison of data.

Enhance physical activities / exercise Social activities Improve diet / nutrition Improve home safety

A single quality appraisal tool was not suitable due to wide heterogeneity of the studies. Four different tools were therefore chosen to cater for the variable study designs. All quality appraisal tools were applied objectively according to the standard recommendations for their use.

Face to face interactions Group sessions Online and telemedicine Educational materials

RESULTS The studies were variable in design and focus, with five (50%) of them undertaken in primary care, four (40%) in community settings and one (10%) within secondary care. The study populations were diverse and included older people, family members, a wide range of health care professionals, practitioners and care home managers. The sample size was also variable, ranging from 12 participants in a qualitative study with semi-structured interviews to 603 in a cross-sectional study. The study quality appraisal exercise graded 2 studies as high quality, 5 as medium quality and 3 as low quality.

NARRATIVE SYNTHESIS A narrative synthesis was undertaken to bring together the findings from the studies, draw conclusions based on the body of evidence, and to then consider potential implications for future practice in the field of frailty education. The framework we used comprised of four elements: (1) Organising the study findings to describe patterns across the studies and consider how the interventions work and for whom; (2) Exploring relationships of study characteristics and findings within and between studies; (3) Assessing how widely applicable the findings may be; (4) Assessing robustness of the synthesis. RESEARCH POSTER PRESENTATION TEMPLATE © 2019

www.PosterPresentations.com

Figure 2: Representation of the dynamic relationship of the themes and concepts found within the included studies; the thematic domains

CONCLUSION This systematic review has found a range of evidence supporting self-management planning, exercise and nutritional educational intervention which has a positive impact on frailty status and quality of life factors and compliments the FCCF. Further work is needed to look at effective, accessible, sustainable delivery systems, including that of online digital platforms, suitable for all groups of people on whom frailty has an impact, be it the older people themselves living with frailty, their families, carers or health care professionals. To reach the largest possible target audience, the programme content would need to be available in a range of formats that are easily accessible to individuals with different preferences and circumstances e.g. face to face consultations and group sessions (at local venues and own homes) and printed material, in addition to interactive digital and online platforms.

REFERENCES Skills for Care. Frailty: A framework of core capabilities; 2018. Available from: http://www.skillsforhealth.org.uk/images/projects/frailty/Frailty%20framework.pdf?s=form. 1

Rachel Viggars: Associate Director of Nursing, North Staffordshire General Practice Federation, 69-71 Stafford Street, Hanley ST1 1LS, England. Email: Rachel.viggars@nhs.net Tel.: 07950 220392. This is a summary of a MSc dissertation submitted to Keele University in February 2020. The views expressed in this are those of the authors and not necessarily those of the NHS.

NO. 455

Prospective evaluation of frailty in individuals with knee pain in the Malaysian Elders Longitudinal Research (MELoR) study

Chiaw Lee Chiew1, Sumaiyah Mat2,3, Kioh Sheng Hui3, Maw Pin Tan2,3 1Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia 2Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia 3Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

RESULTS

INTRODUCTION Knee Osteoarthritis (OA) is a major cause of physical impairment in older persons. Few studies have determined the relationship between the presence of OA and frailty.

OBJECTIVE To evaluate the prospective relationship between knee pain and frailty in a Malaysian longitudinal cohort.

METHODS Data: MELoR study (From home-based computer-assisted questionnaires & hospitalbased health-checks from 2013-2015). Frailty status was determined in 2019. Setting: Klang Valley, Kuala Lumpur Participants: Aged 55 years and above Measurements: Knee pain was determined with a single Frailty status was determined prospectively using the FRAIL scale.

CONCLUSION Knee pain was associated with an increased risk of frailty at 5-years follow-up in an urban population in Kuala Lumpur. More detailed evaluation using imaging and clinical diagnosis of osteoarthritis is now indicated. Future studies should also seek to identify modifiable risk factors for the development of frailty in individuals with knee OA and develop strategies to prevent frailty.

FUNDING The MELoR study is now AGELESS which is funded by the Malaysian Ministry of Higher Education Long Term Research Grant Scheme (LRGS/1/2019/UM/01/1).

Data from 1226 individuals were included, mean age (SD) = 68.97 (7.48). 33.3% had knee pain. Individuals with knee pain were more likely to be female and ethnic Malay. Among the individuals with knee pain, majority had comorbidities of diabetes, hypertension, dyslipidaemia or obesity. There was a significant increased risk of frailty among the individuals with knee pain. The association remained significant even after adjustment for the confounders. Table 1: Baseline characteristic (n=408)

Knee pain (n=408),% Female Ethnic

66.2 Malay

43.4

Chinese

24.8

Indian

31.9

Comorbidities

With

Without

Diabetes

40.1

29.9

Hypertension

38.3

27.0

Dyslipidaemia

38.4

26.5

Obesity

52.6

30.2

Table 2: Associations between knee pain and frailty Frailty, OR (95%CI)

Knee pain Unadjusted

3.03 (1.92-4.79)

Adjusted*

2.71 (1.61-4.58)

*Adjusted for demographic differences and comorbidities

Individuals with knee pain were more likely to develop frailty at follow-up. After adjustment for confounders, individuals with knee pain were more significantly to develop frailty at follow-up.

REFERENCES Buta, B. J., Walston, J. D., Godino, J. G., Park, M., Kalyani, R. R., Xue, Q. L., . . . Varadhan, R. (2016). Frailty assessment instruments: Systematic characterization of the uses and contexts of highly-cited instruments. Ageing Res Rev, 26, 53-61. Misra, D., Felson, D. T., Silliman, R. A., Nevitt, M., Lewis, C. E., Torner, J., & Neogi, T. (2015). Knee osteoarthritis and frailty: findings from the Multicenter Osteoarthritis Study and Osteoarthritis Initiative. The journals of gerontology. Series A, Biological sciences and medical sciences, 70(3), 339-344.

Contact details: Email: ageless@um.edu.my https://www.facebook.com/agelessresearchmy

Nutrition, Sarcopenia and Frailty Weihong Du and David G Smithard

10 6

Fig 2

4 2

r=0.4887, p=0.00162

0 0

8 Median

MEOF II 10 8

CFS vs SARC-F

SARC-F

MEOF II

CSF 75

% Volume Food Eaten

r=0.80296,

SARC-F

<50 Fig 1

Discussion

0 0

CFS

MEOF II vs SARC-F

8 SARC-F

100

References

Fig 3

-2 1.Smithard et al. Inter-Relationships between Frailty, Sarcopenia, Undernutrition and Dysphagia in Older People Who Are Admitted to Acute Frailty and Medical Wards: Is There an Older Adult Quartet? Geriatrics 2020, 5, 41; doi:10.3390/geriatrics5030041 .McWhirter and Pennington. Incidence and recognition of malnutrition in hospital. BMJ 1994; 308:945-8. 3.Westergren et al. Minimal Eating Observation Form: Reliability and Validity. The Journal of Nutrition Health and Aging 2009; 13(1):6-12 4.Smithard et al Evaluation of the prevalence of screening for dysphagia among older people admitted to medical services an international Survey. OBM Geriatrics 2018, 2, doi:10.21926/obm.geriatr.1801xxx

39 patients were observed. Mean age was 82.38 years; median CFS 6 (3-8); median Sarc-F 4(0-9). Median MEOF II was 0 (0-5). Two patients were referred to dietetics and 4 to SLT. 7/40 (17,5%) were at high risk for undernutrition, a further 8/40(20%) were at moderate risk. 82% were severely frail , the remaining were mildly frail. 94% (16/17) exhibited sarcopenia. There was a trend higher MEOF II scores, presence of frailty and sarcopenia and reduced amount eaten (Fig 1). The relationship between MEOF II, Sarc-f and CFS are demonstrated in Figs 2-4.

MEOF II vs CFS

Methods

Older people admitted to a Frailty Ward were directly observed during lunchtime by WD. The Minimal Eating Observation Form Version II (MEOF-II) (3)was used to document how much they ate. Frailty status (CFS) and presence of Sarcopenia (Sarc-F), whether a referral to dietetics or speech and language therapy (SLT) was completed were documented.

Results

Queen Elizabeth Hospital, Woolwich and University of Greenwich.

CFS

Many older people admitted to hospital are malnourished /at risk of malnourishment (30%), have swallowing problems (55%), frail (25%), have sarcopenia (50%) or a combination of these (1). On admission to hospital frail older people are at significant risk of worsening nutritional status and prolonged hospital stay. Nutritional status should be assessed, nutritional risk identified, documented, food intake monitored and where appropriate referral to a dietitian should occur and red tray instituted (2). The question remains, do staff recognise that frail older people may not be eating their food increasing their risk of poor nutrition and outcome.

6 4

Fig 4 r=0.4395, p=0.00512

2 0 0

4 MEOF II

Many patients admitted to hospital are at risk of protein calorie malnutrition (4). This is of particular concern in older frail adults. This is exacerbated by the inevitable reduced intake when acutely unwell coupled with the repetitive missing of meals for investigations. Screening, observation and monitoring of nutritional intake should highlight concerns and trigger the institution of the Red Tray, referral for dietary assessment and where appropriate swallowing assessment. This study high lights that a significant number of older people are frail, fail to complete meals, are at significant risk of under nutrition, yet proactive intervention does not occur.

Conclusion

Clinical staff need to be more alert to the nutritional needs of frail older adults.

The Impact of the Bone MDT: Exploring Changes in Bone Protection Decisions Between 2015 and 2018 Dr Stephanie Brooks (ST4 Geriatrics), Dr Trevor Wheatley (Consultant Endocrinology), Dr Adam Harper (Consultant Orthogeriatrics) and Dr Louise Pack (Consultant Orthogeriatrics)

Princess Royal Hospital, Haywards Heath

Aims

Results

This audit aimed to assess the impact of the newly introduced Bone MDT by reviewing treatment decisions prior to and post its implementation.

Sixty cases from September and October 2015 were reviewed; seven were excluded either as they had incomplete discharge summaries or they died as inpatients. Sixty-four cases from September to November 2018 were reviewed; eight were excluded due to inpatient death or incomplete discharge summaries. The demographics of patients from both years had similar average ages, age ranges and median ages.

Introduction The Hip fracture Metabolic Bone Multidisciplinary Team (Bone MDT) was developed in June 2016 as a collaboration between orthogeriatricians and the metabolic bone team. The objective was to improve the quality of bone protection treatment decisions. All patients with complex decisions around bone health were discussed at the MDT. Typically, these tended to be younger patients, those with osteoporosis treatment failure (defined as hip fracture despite more than one year of therapy) or those with very low bone density. Most of these patients had DEXA scans, and all had relevant blood tests to ascertain underlying risk factors for osteoporosis. Patients were discussed individually and for those with equivocal indications for treatment, a FRAX score was used to guide further care. Those potentially suitable for treatment with teriparatide were brought back to a specialist metabolic bone clinic.

Methodology Case notes for fractured neck of femur patients were reviewed for admissions from September to October 2015 and from September to November 2018. For both time periods the inpatient list, discharge summary and blood tests were reviewed in order to collect data regarding demographics, type of surgery, co-morbidities, calcium and vitamin D levels, bone protection prior to admission and bone protection decision at discharge.

Bone protection decision after discharge in 2015 Unknown

6% 6%

Nothing Adcal D3 only

Fultium or alfacalcidol

Alendronic acid only

39%

26%

Adcal D3 and alendronic acid Adcal D3 and risedronate Adcal D3 and zolendronic acid zoledronic acid Adcal D3 and denosumab

Unknown

12%

Adcal D3 only

32% 27%

Adcal D3 and alendronic acid Adcal D3 and risedronate

11% 11%

Bone protection decisions at discharge for both years are shown in the pie charts below.

Discussion Overall, there is a fall in bisphosphonate use and a significant increase in the frequency of denosumab prescription after the introduction of the Bone MDT. This reflects the sharing of greater knowledge and experience from the MDT members. The slight fall in zoledronate prescribing is likely to reflect the practicalities of giving the medication. Currently, there is no easily accessible facility in our Trust to give zoledronic acid infusions to outpatients. Since mid-2018, it has been possible to prescribe denosumab in primary care, along with more flexibility for the use of denosumab in male patients with osteoporosis (currently NICE guidance limits this to female patients.) There is also an increase in the number of patients having DEXA scans prior to bone protection decisions, with almost a third of those patients subsequently receiving denosumab. This reflects clearer pathways for following up the DEXA scans and acting on the results. Other benefits of the Bone MDT include more extensive investigation for the underlying causes of osteoporosis; capturing this was not part of this project. Some patients were followed up in a specialist endocrinology clinic with a view to starting teriparatide. While the orthogeriatricians have a good knowledge and experience of managing osteoporosis, this MDT facilitated better decision-making through access to the further specialist skills from the endocrinologist and specialist nurses. The MDT approach lends itself to more holistic decision making, while also keeping down referrals to a specialist endocrine clinic.

Fultium or alfacalcidol Alendronic acid only

In 2018, 77% of patients were admitted on no bone protection. Around 5% were admitted on a bisphosphonate rising to 16% on discharge. No patients were admitted on denosumab, but 27% were discharged having received it in hospital, or with a plan to receive it from their GP.

DEXA

Bone protection decision after discharge in 2018

In 2015, 83% of patients were admitted with no form of bone protection. Around 6% of patients were admitted on a bisphosphonate and 36% were discharged on a bisphosphonate. Less than 2% of people received denosumab prior to their admission, with this number rising to 9% at discharge.

Overall this audit has shown that, on a hip fracture unit, interdisciplinary team collaboration in the form of a MDT resulted in the prescribing of a broader range of medications for fracture prevention, including some treatment protocols not previously considered. This Individual case discussion clearly enhanced the delivery of personalised medicine.

zoledronic acid Adcal D3 and zolendronic acid Adcal D3 and denosumab DEXA

Contact details for further queries: stephanie.brooks7@nhs.net

Prevalence and impact of frailty in patients hospitalised with COVID-19. The Salford Experience in waves 1 and 2 1

Amarah Khan , Fernanda Ramon Espinoza , Thomas Kneen , Anna Dafnis , Hala Allafi , Ben Carter , 1 2 1 1 1 Maria Narro-Vidal , Roxanna Short , Angeline Price , Rebecca Upton , Arturo Vilches-Moraga 1

Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience King's College, London

Introduction & Aims The COVID-19 pandemic has had an extensive impact on the frail older population, with significant rates of COVID-related hospital admissions and deaths amongst this vulnerable group. During the first wave of the pandemic, NICE published a rapid guideline recommending frailty assessment of all adults on admission to hospital, and suggested using the Clinical Frailty Scale (CFS) as part of a holistic assessment of older patients with COVID-191. The COPE study2, which is a multicentre European observational cohort study, looked at the effect of frailty on survival in patients with COVID-19, and found that frailty was widely prevalent and associated with both earlier death and longer length of stay in patients hospitalised with COVID-19.

Results (cont.) Fig. 2: Prevalence of frailty in waves 1 & 2

Fig. 2: Logistic regression; CFS x Wave

There is little evidence comparing the prevalence and impact of frailty amongst patients hospitalised with COVID-19 in wave 1 vs. wave 2 of the pandemic. We have conducted a single site study comparing prevalence and impact of frailty in the first and second waves.

Methods Prospective observational study of all consecutive patients admitted to Salford Royal NHS Foundation Trust (SRFT) 27/02/2020 to 28/04/2020 (Wave 1), and 01/10/2020 to 10/11/2020 (Wave 2) with COVID-19. Patient demographics, co-morbidities, biochemical parameters, and frailty (using the Clinical Frailty Scale) were collected. Analysis: Cox proportional hazards (PH) model associating wave and frailty with mortality (time to in-hospital mortality). Logistic regression associating patient characteristics with wave. Both models adjusted for patient characteristics . Kaplan-Meier - effect of frailty on time to mortality in wave 1 vs wave 2 (Fig. 3). Age; sex; smoking status; hypertension; diabetes; kidney function (eGFR); coronary artery disease; CRP.

Results Wave 1 patients: N=429 (42% female); median age 72; N=160 deaths (37%); N=212 (49%) frail (CFS 5-9). Wave 2 patients: N=271 (38% female); median age 73; N=80 deaths (30%); N=106 (39%) frail.

Fig. 3: Time to mortality by CFS in waves 1 & 2

Conclusion Frailty is highly prevalent amongst patients of all ages admitted to SRFT with COVID-19. Patients were more frail in the first wave of the pandemic. Higher scores of frailty were associated with increased mortality. This is consistent with previous studies looking at the impact of frailty on survival in COVID-19. 2,3,4 Our findings highlight the importance of assessing for frailty on admission and support the use of the Clinical Frailty Scale as part of a holistic assessment in older adults admitted with COVID-19. Our findings would suggest that the Clinical Frailty Scale could help identify those patients who are at risk of poor outcomes in COVID-19.

References

Protective effect of Wave 2 on mortality: aHR=0.71 (95% CI 0.53-0.94) Frailty associated with increased mortality (Fig.1), after adjustment for age, wave, and other patient characteristics.

National Institute for Health and Care Excellence. COVID-19 rapid guideline: critical care in adults. Published 20 March 2020. www.nice.org.uk/guidance/ng159 (accessed 21/03/2021)

Hewitt et al. The effect of frailty on survival in patients with COVID-19 (COPE): a multicentre, European, observational cohort study. The Lancet Public Health. 2020 Aug 1;5(8):e444-51.

Pranata et al. Clinical frailty scale and mortality in COVID-19: a systematic review and dose-response meta-analysis. Archives of gerontology and geriatrics. 2020 Dec 15:104324.

De Smet et al. Frailty and mortality in hospitalized older adults with COVID-19: retrospective observational study. Journal of the American Medical Directors Association. 2020 Jul 1;21(7):928-32.

Patients were more frail in Wave 1 (Fig. 2). Effect of frailty more pronounced in Wave 1 vs Wave 2 (Fig. 3)

HR (95% CI) CFS 4 1.73 (1.13-2.67) CFS 5-6 1.87 (1.35-2.59) CFS 7-9 2.15 (1.50-3.08)

p 0.012 <0.001 <0.001

aHR (95% CI) 1.45 (0.92-2.29) 1.45 (0.99-2.12) 1.58 (1.03-2.43)

Fig. 1: Time to mortality (Ref CFS 1-3)

p 0.114 0.058 0.035

Improving the Recognition and Management of Frailty through In-Situ Simulation Dunnell L, Chu K, Barnard A, Walker G

1. INTRODUCTION Knowledge of frailty varies significantly among hospital staff 1 Frail patients are more likely to suffer adverse events in hospital2 Managing frailty requires an inter-disciplinary approach3 - simulation is advantageous for interprofessional education4 2. METHOD 10 sessions delivered with frailty-based scenarios- hypoactive and hyperactive delirium/falls and fractured NOF/urinary retention and constipation/medication side effects/escalation decisions/new stroke/fast AF/heart failure/aspiration pneumonia 1 hour long sessions consisting of one simulated scenario with facilitated debrief Delivered in-situ on the OPU (Older Persons Unit)

4. DISCUSSION An in-situ frailty simulation programme has been successfully implemented The programme has been hugely popular amongst staff It has improved staff knowledge of technical and human factors skills when managing frail patients Newsletters used to share learning Latent threats identified and escalated e.g. equipment access for all staff 5. NEXT STEPS Increase multidisciplinary faculty and scenarios around discharge planning and challenging conversations Expand across OPU and, share methods and scenarios with other units and care homes. Funding secured for frailty manikin What was good about the sessions?

3. RESULTS 44 participants to date (33 completed surveys) 100% of participants found sessions useful Common themes of learning included communication (51%), teamwork (45%), leadership (18%), escalation (18%) as well as technical learning for managing frail patients (36%)

(Pre v Post Session, N=23) Recognising a frail patient Assessing a frail patient Recognising deterioration in a frail patient Anticipating adverse outcomes in frailty Managing a patient who has had a fall Managing a patient with immobility Managing a patient with delirium Managing a patient with incontinence Recognising susceptibility to medication

Pre-Session

Post-Session

REFERENCES: 1) NIHR Dissemination Centre. Comprehensive care, Older people living with frailty in hospitals. 2017. 2) ) Hewitt D, Booth MG. The FRAILadverse-event incidence in the longer term, at one year following intensive care unit treatment A retrospective observational cohort study. Journal of the Intensive Care Society. 2020;21(2):124-133 3)Turner G, Clegg A. Best practice guidelines for the management of frailty: a British Geriatrics Society, Age UK and Royal College of General Practitioners report. Age and Ageing, Volume 43, Issue 6, November 2014, pp. 744 747. 3) Palaganas J, Epps C, Raemer D. A history of simulation-enhanced interprofessional education. Journal of Interprofessional Care, 28(2), pp. 110-5.

7 8 Level of confidence (out of 10)

Improving Advance Care Planning Skills in Junior Doctors Dr Samuel Cohen SpR, Dr Raunak Singh SpR, Dr Naureen Khalid SpR, Dr Johnathan Young CMT, Dr Mohanad Aldiwani IMT, Dr Debashree Roy IMT, Dr Ian Edwards Consultant Geriatrician

Abstract - Junior doctors are increasingly encountering Advance Care Planning (ACP) when they look after frail, older or multi-morbid patients during their hospital rotations. However, there remains a lack of formal training and resources, particularly with DNACPR discussions and when engaging patients and their loved ones with Emergency Health Care Planning (EHCP). We aimed to assess the need for ACP, improve the infrastructure by which ACP is delivered, and better support junior doctors to have these difficult conversations. Discharges from the Geriatrics Department at Kettering General Hospital were reviewed in May 2019. Of 32 patients, 100% met at least one SPICT TM criterion, with median of 4 criteria, thus indicating a high need for ACP in this cohort. Despite this, only one discharge letter included an EHCP and two had a request for GP colleagues to complete one. We introduced a focused communication skills training session delivered at departmental teaching, which included a combination of simulation training and lectures, utilising BGS guidance. We additionally designed and implemented an EHCP template to aid junior doctors discussions. This could also be copied to the discharge letter, to facilitate safe transfer of care to primary care. Qualitative questionnaires demonstrated an improvement in both knowledge and confidence amongst junior doctors following the training session. Evaluation of discharges again in January of 2020 reconfirmed a similar need for ACP, but following our interventions, the number of EHCP s performed had increased. Of 22 identified patients 4 had a completed EHCP and 3 were requested for completion by their GP. We have shown that there is a necessity for ACP to be considered for Geriatrics inpatients, and that providing structure and training in this challenging area offers benefit to both patients and junior doctors. Introduction Advance Care Planning is an important skill for all doctors to be familiar with but particularly in those who will encounter frail patients or those with life limiting conditions and relates to the process of shared decision making which a patient and a healthcare worker embark on together to avoid inappropriate, unpleasant or futile interventions should the patient become unwell in the future. Recently there has been a great deal of work on a national level with the introduction of ReSPECT in many hospitals that flipped the focus from being paternalistic and simply imposing it on patients or their families and encouraging staff to engage patients in these discussions. Whilst working at Kettering General Hospital it was noted that though there was a robust process for Do Not Attempt Cardiopulmonary Resuscitation (DNA-CPR) and Ceiling of Care (C.O.C) decisions, there was a lack of procedure for other aspects of Advance Care Planning. This was surprising as it was not uncommon for the ward round plan to include Advance Care Plan in the Care of Older Persons ward rounds. It was also noted that though the need for this was important, the seniors were often unable to find time to engage in these discussions, and the juniors were unfamiliar with the process let alone comfortable in having the discussions. Our goal was to introduce the idea of an Emergency Health Care Plan , a particular type of Advance Care Plan which includes details as to what to do in specific medical situations not included in DNA-CPR or COC decisions, to the trust as well as upskilling our juniors to feel comfortable with having these discussions (with appropriate senior input). We did this by introducing a novel combined simulation-lecture method of teaching and introducing a template that could be directly copied to the patient s discharge letter. Methods - We reviewed notes of patients discharged from the Care of the Elderly wards in May 2019 noting the amount of SPICT criteria they had, whether an advanced care plan was in place or whether a GP had been requested to complete one. Once complete, we introduced a new teaching session with a combination of simulation (focusing on issues regarding advanced care planning). Alongside this we collected quantitative and qualitative data both assessing the candidates knowledge (using a selection of 5 true/false questions), and their self perceived abilities with regards to advance care planning with a series of questions that they would suggest either strongly disagree through to strongly agree. The same questions were distributed both before and after the teaching session. We also introduced an EHCP template to the department available on the shared drive. The agreed process was that seniors would assess the case and make a recommendation as to what should be on the EHCP that the juniors could then discuss with the patient or their families. If agreed the plan could then be directly transferred to the patient s discharge letter Following this we reviewed the notes for patients discharged in the month of January 2020. The same parameters were re-evaluated. We also collated GP feedback via a questionnaire both assessing how useful they felt out EHCP template was and collected written feedback as to how we could improve.

Example Simulation Learning point includes Relative s misunderstanding of the role of DNACPR and explanation of Advance care planning. Actor s stem You are the oldest child of Margaret a 78 year old woman with advanced dementia, heart failure and multiple strokes previously. You have been told by her care home that she was admitted to hospital after she became drowsy and that the doctor felt she may have a chest infection. In the last year she has had 7 admissions to hospital for the same thing. She normally has challenging behavior associated with her dementia but gets significantly worse whilst she is in hospital and finds the hospital environment incredibly distressing. Every time she comes out of hospital she looks worse than she did before. Initially please appear frustrated and slightly angry, points of contention include that no one has called her about what is going on. You don t want mum to stay in hospital because of the level of distress. Also please be frustrated that on the last admission you were told she was dying and a DNA-CPR was filled in, and yet even though this was the case the care home still called the ambulance in the middle of the night and had her sent in. Doctor s stem You are a junior doctor working on the ward looking after Margaret, a 78 year old woman with advanced dementia who you have treated for aspiration pneumonia. She has finished her antibiotics and is ready to go home and SALT have seen her and advised on some fluid consistencies. The letter is done and the care home have agreed to have her back. The ambulance is booked for the next half an hour. The nurses have asked you to speak to the patient s son/daughter who is upset and is wanting to speak to a doctor. Your consultant and registrar are both in clinic.

Results In the Pre-intervention arm we reviewed 32 sets of notes. Of these all had at least one SPICT indicator but on average had 3 General indicators and 2 clinical indicators. The amount of admissions over the past year ranged from 1 to 7. We found only one patient had an Advance Care Plan and we had requested the GP to complete 2. Pre and post-questionnaires showed that the teaching resulted in an improvement in both the true/false questions (Fig 1) and the self perceived questioning (Fig 2). General feedback was very positive (Fig 3). Fig 1- True/False questions pre and post teaching intervention Fig 2 Self Perceived questions pre and post teaching intervention -note correct answers to all are false series 1 pre, series 2 post Series 1 pre, series 2 post 1-An advanced care plan is legally binding? 2-An ADRT is valid when the patient has capacity? 3-ACP and EHCP are the same thing? 4-There are 3 stages to capacity assessment? 5-An IMCA always needed when there is no next of kin? 6-If decision is unwise a patient is presumed to lack capacity?

Fig 3- Word-cloud of feedback from teaching intervention

1 I feel Confident I can identify an ACP need. 2 I feel Confident having DNACPR discussion 3 I feel Confident setting up EHCP 4- I feel my skills in ACP have improved. 5 I would Support further teaching would be useful 6 - Visual aid for EHCP useful

The repeat data showed that of 22 discharges in January 2020, the SPICT criteria was similar to the pre-intervention data. 4 had an EHCP and 3 had a GP request to complete one, demonstrating an increase in the proportion of patients who left the department with an Emergency Health Care Plan (Fig 4). We also presented our data at a local meeting for GPs in the area and demonstrated that they too felt a need for Advance Care Planning and that it was useful for the process to be started in hospital. Though some improvement in patient/relative understanding of the process was needed, interestingly there was a strong desire for a separate letter detailing the EHCP.

Fig 4

Fig 5

Fig 6- Brief summary of written comments from Surveymonkey distributed to Northamptonshire GPs There should be a shared proforma between primary and secondary care. Clear transcription of whom the decision has been taken discussed (patient/family). ACP cannot cover every eventuality so there needs to be some limitations for this. Some of the wording could be worded slightly more sensitively and compassionately

Learning points - We demonstrated a clear need for advance care planning in our population group and were able to introduce the concept of Emergency Health Care Planning to the department, as well as improve the numbers of the patients/patient families who were having these conversations. - Interestingly we note that prior to the teaching many of our doctors felt comfortable with having DNA-CPR discussions but not about discussing more complex issues. Following the teaching intervention they felt much more confident in having these discussions. - By upskilling and supporting our juniors we were able to empower them to contribute to the process and could improve the proportion of patients leaving hospital with either a EHCP or recommendation for GP to engage. - The impact on the working lives of GPs is encouraging however further needs to be done to ensure that the respective plans are compatible, and ideally would move towards a shared plan that can be accessed and updated by both parties. - The above demonstrates a clear need to introduce training for junior doctors on Advance Care Planning in addition to DNA-CPR discussions.

M Thomas 1; K Cookson 1; R Clark 1; L Pearce 1; J Fox 2; A Price 2 1: Department of Colorectal Surgery, 2: Department of Ageing and Complex Medicine

472 A pilot Colorectal and Geriatric Medicine clinic for older, frail patients referred via a 2 week wait pathway Background The two week wait colorectal referral pathway was introduced to expedite referrals where cancer was suspected, to enable prompt diagnosis +/- intervention. Increasing numbers of older, frail patients are being referred via this pathway, though invasive investigation and interventions are often not possible in this group of patients. Their needs may be better met through holistic assessment, rather than a solely surgical focus. A joint colorectal and geriatric medicine assessment clinic was piloted, delivered by a colorectal specialist nurse and an advanced clinical practitioner in geriatric medicine.

Methods Patients > 65 years with a Clinical Frailty Scale score of 5 or more at referral were directed to the joint assessment clinic. A telephone consultation was undertaken, incorporating standard two week wait assessment and aspects of comprehensive geriatric assessment.

Results 42 patients were reviewed in the clinic. The mean age was 86.1 years and mean CFS 5.9. 28 patients decided against investigation. 12 patients underwent CT, and 2 CT virtual colonoscopy. No patients underwent endoscopic investigation. Of those who had investigation, no cancers were identified. 1 patient was referred on for polypectomy. 5 patients had severe diverticular disease, which accounted for their symptoms. Medication recommendations were made for 30 patients, some of which led to cessation of symptoms. Onward referrals were made to a community geriatrician, diabetes and continence teams and palliative care specialists.

Conclusion

9 patients met criteria for advance care planning. This was commenced during the consultation and communicated back to the referring clinician for further action.

Older, frail patients are often not able, nor wish to undergo, invasive investigations. Further work is needed to determine the most appropriate referral pathway for this group of patients. Holistic assessment that leads to improvement in symptoms and future planning may not be achievable through a solely surgical assessment.

Abstract No: 475

Developing a Virtual Care Home Support Forum During the COVID-19 Pandemic

L Ferrigan1, R Hartley1, E Hadley1, L Steward2, S Ngwenya2, J Harmer2 3, A Robinson2, S Cosmos3, I Wilkinson1, P Tucker1, A Flores1, R Baker1. 1 Surrey and Sussex Healthcare NHS Trust 2 Integrated Response Team Sussex Community Foundation Trust 3 First Community Health and Care CIC, East Surrey

1. Introduction From 02 March- 12 June 2020, COVID-19 was the main cause of death in male care home residents (33.5%) and second for female (26.6%). 1 By 01 May 2020, the death rate from all causes in care homes exceeded that in hospital (6409 versus 6397).2

2. Aims Improve awareness and understanding of COVID-19 Improve residents care Improve residents and staff safety

Thus, care homes had to rapidly adapt to facilitate safe care of patients and staff.

3. Method An expert outreach team visited a number of care homes in Surrey and Sussex to explore COVID-19 issues in the care homes. Key education and training themes were identified to help support staff members in providing safe care during the pandemic.

Outreach Team

4. Themes Identified Rapid patient discharges from the acute sector PPE provision IPC measures Ability to cohort residents End of life patients Maintaining safe staffing Limitations to visiting Loss of face to face input from community teams

Consultant Geriatrician Deputy Chief Nurse Consultant IPC Nurse Community Care Home Matron

5. Strategy

Virtual Care Home Forum established where a series of virtual teaching, training and peer support sessions were hosted either live or ondemand, accessible for all care home staff

6. Results 12 sessions were held Average attendance - 25 people 100% felt the sessions had improved their understanding of the topic 100% felt the knowledge and skills obtained from the sessions would be useful in their job 87.5% agreed the sessions would impact or change their practise 100% felt more supported during the pandemic

Session 1

Introduction

Session 2

Covid myths and mythbusters

Session 3

Infection Control and safeguarding

Session 4

Dietician

Session 5

Reuse of medications

Session 6

EOLC and ACP

Session 7

NEWS 2 and deteriorating patient

Session 8

SBAR

Session 9

Mouthcare matters

Session 10

Peer support Q&A

Session 11

Wellbeing and emotional support

Session 12

Dementia and residents walking with purpose in care homes

7. Feedback bit more supported and

8. Conclusion

References Deaths involving COVID-19 in the care sector, England and Wales. Office for National Statistics, 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsd eathsandmarriages/deaths/articles/deathsinvolvingcovid19intheca resectorenglandandwales/deathsoccurringupto12june2020andregi steredupto20june2020provisional What has been the impact of COVID-19 on care homes and the social care workforce? The Health Foundation, 2020. https://www.health.org.uk/news-and-comment/charts-andinfographics/what-has-been-the-impact-of-covid-19-on-carehomes-and-social-care-workforce

8. Next Step We plan to continue providing training, teaching and support through this means in the future.

Virtual sessions proved to be an excellent modality for providing education and training to support our community colleagues, remaining complaint with government restrictions.

If hospital Wijayasiri P, Munir M, Than H, Sahota O.

NIHR Nottingham Biomedical Research Centre Nottingham University Hospitals (NUH) Trust

Healthcare of the Older Person (HCOP), Nottingham University Hospitals NHS Trust, UK

100 participants surveyed (face-to-face with no prior warning, on 3 separate HCOP wards over 7 days)

68 staff

32 patient relatives

QUESTIONS: Can you name 3 posters on this ward? Here is a list of titles of all of the posters on this ward currently, which topics sound useful to you? What information do you want? Could the ward walls be used for a different purpose?

OUR INTERVENTIONS Photos taken on NUH HCOP wards (Dec 2020)

Interventions were carried out on one, 28 bedded HCOP ward over 14 days

Duplicate posters/ posters > 2 years old removed. Total poster count reduced from 33 22.

3 POSTER RECALL 100% 80% 60% 40% 20% 0% Staff

Floor to ceiling colourful mural painted near centre of ward.

Relatives

Abe to recall 3 posters Not able to recall 3 posters

UNMET INFORMATION NEEDS STATED BY > 1 RELATIVES

staff photos (15%)

discharge pathway (21%)

confusion, incontinence, electrolyte imbalance and poly-pharmacy)

paintings/art (32%) poetry (15%)

falls (21%)

created, covering:

SUGGESTIONS FOR ALTERNATIVE WALL USES STATED BY > 1 PARTICIPANT

thank you letters (10%)

delerium (19%) what staff uniforms mean (6%) palliative care12%) nutrition (6%)

ARE THESE LISTED POSTER TOPICS USEFUL?

100% 80% 60%

Common Appointments After Discharge

40% 20% 0% Staff

Relatives

Atleast 1 useful topic No useful topics

20 relatives (new participants) were directed towards the patient information board and mural when visiting the ward, and asked to anonymously rate how a) useful and b) accessible they found the information (Scale 0 5(best)). The purpose of the study was explained, and free-text space was left for further suggestions. 85% liked the mural. 30% wanted more information on 45% called for more artwork still. Mean accessibility = 3.55 Mean usefulness = 3.60

Pramudi Wijayasiri: Pramudi.Wijayasiri@nottingham.ac.uk This was funded NIHR Biomedical Research Centre.at The views expressed The NIHR Nottingham Biomedical Research Centre partnership between Nottingham University Hospitals NHS Trust and Thisresearch work was done by asthe part ofNottingham a quality improvement project Nottingham University Hospitals Trust. Registration number: 19 is a072C are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of the University of Nottingham, supported by Nottinghamshire Healthcare NHS Foundation Trust and Sherwood Forest Health and Social Care. Hospitals NHS Foundation Trust. We are hosted by Nottingham University Hospitals.

Nottingham ICE (N-ICE) Cream -A more nutritious, palatable and preferred high protein, vitamin D fortified vanilla ice cream A step towards improving patient care

N-Ice Cream

Arunpreet Sahota 1, Jack Wallman 2, Richard Worrall2 and Opinder Sahota3. Medical Student, Leicester University; 2Department of Food Sciences, University of Nottingham; 3Department of Healthcare for Older People, Nottingham University Hospitals NHS Trust, UK

Introduction

Oral Nutritional Supplement (ONS) drinks are commonly used to support nutritional intake in older people, however these are poorly consumed and frequently wasted. Fortified ice-cream offers a more acceptable ONS.

Methods

In collaboration with the University of Nottingham, Department of Food Sciences, we developed a high protein vanilla ice cream (20g of protein/120mL), fortified with vitamin D (400IU), Nottingham ICE Cream: (N-ICE) Cream An anonymised Google consumer survey was untaken amongst older patients from the Nottingham Osteoporosis Patient Support group who each had a serving of 120ml to taste. Further comparison was made with an over-the-counter Oral Nutritional Supplement drink Amyes Complete energy and protein content to N-ICE Cream).

(similar in

We evaluated (on a rating scale of 1-10) 5 characteristics

Taste 1 unpleasant to 10 tasty

N-ICE Cream

Amyes

Results 32 participants completed the consumer survey. The mean (SD) age of the patients was 79.1 (4.5) yrs.

Percentage of the participants and the proportion of 120ml they were able to consume

The mean (SD) scores out of 10: Taste was 8.95 ± 1.02 Mouthfeel 9.14 ± 0.98 Smell 8.86 ± 1.06

N-ICE Cream

64% ate all 120ml

N-ICE Cream

N-ICECream

Appearance 8.95 ± 1.12

22% ate ¾

10% ate ½

4% ate ¼

Colour 9.10 ± 1.14 Overall acceptability was 8.92 ± 1.1.

Participants who preferred N-ICE Cream

Taste 94% (30/32)

PMouthfeel 91% (29/32) N-Ice Cream

Smell 88% (28/32)

Participants who preferred

Taste 6% (2/32)

Mouthfeel 9% (3/32) Smell 13% (4/32)

Overall if given a choice, 30/32 (94%) of the participants preferred N-ICE Cream over the Amyes Complete ONS drink. 2. The retail cost of Amyes Complete was £2.50 and 88% (28/32) of the participants said they would be willing to pay the same amount for N-ICE Cream.

Conclusion N-ICE Cream is highly acceptable, nutritious and preferred by the consumer group evaluated when . Further studies are now planned in in-patients.

Developing a Novel Teaching Programme for Physician Associate Students Within Elderly Medicine ne Dr Samuel Mottaghi-Taromsari, Dr Lindsey Wileman

SMART Aims & Driver Diagram

Introduction

Aim/Outcome

Primary Driver

as a learning opportunity and organised rotation 2. To increase the average level of student confidence in assessing falls

and understanding of frailty to over 90% 3. To arrange 1 formal teaching session for the students each week and

Doctors /Physician Associates availability to teach

Doctors/ Physician Associates delivering teaching

1. To receive 90% positive feedback regarding the clinical attachment

To receive 90% positive feedback regarding the clinical attachment as a learning opportunity

Subjects and presentations Organisation of the placements

Rotation through different areas of elderly medicine Once weekly protected teaching on key general medicine and geriatric topics Feedback forms for start and end of placement Feedback forms after each teaching session Incorporate feedback into improving sessions

Students availability

Students

to achieve an average of 90% positive feedback

Change Ideas

Secondary Driver

Honest feedback

Figure 1: Driver diagram of SMART aims and proposed changes

Agree

The placement was organised and I felt supported

Neither Agree nor Disagree

Disagree

Strongly Disagree

Figure 2: A graph showing the overall assessment of the students regarding the placement

10 9 8 7 6 5 4 3 2 1 0

8.1% increase 9.9

9.1

Average subjective confidence rating from student feedback

The placement met my learning needs Strongly Agree

Average subjective importance from student feedback

100 90 80 70 60 50 40 30 20 10 0

10 9 8 7 6 5 4 3 2 1 0

19.8% increase 8.6 6.9

Pre-Placement Post-Placement

Pre-Placement Post-Placement Strongly Disagree

Strongly Disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly Agree

0 10 20 30 40 50 60 70 80 90 100 Percentage of students feedback Strongly Agree Neither Agree nor Disagree Strongly Disagree

Agree Disagree

0 10 20 30 40 50 60 70 80 90 100 Percentage of students feedback Strongly Agree Neither Agree nor Disagree Strongly Disagree

Agree Disagree

Figure 3: 2 graphs summarising the overall verdicts of the students regarding the organised teaching sessions

Discussion and Next Steps

10 9 8 7 6 5 4 3 2 1 0

47.1% increase 8.5

4.5

Pre-Placement Post-Placement

Average subjective confidence rating from student feedback

Disagree

Neither Agree nor Disagree

Average subjective confidence rating from student feedback

Methodology

Percentage of PA students

Results

10 9 8 7 6 5 4 3 2 1 0

29.0% increase 9.3 6.6

Pre-Placement Post-Placement

Figure 4: Graphs showing the average response scores from the students pre and post placement

References BMJ-29306/349-WYTH-335-21

Outcomes of hospitalised patients with covid-19 six months after index admission Ellen StClair Tullo , Catherine Dotchin , Sharlene Jaiswal 1,2

1,3

1. Northumbria Healthcare NHS Foundation Trust, 2. NIHR Newcastle Biomedical Research Centre in Ageing and Longterm Conditions, Newcastle University, 3. School of Population and Health Sciences, Newcastle University 4. Newcastle University Medical School

Background: Covid-19 (C-19) in the UK

Results at 6-months (n=252)

Rapid research on C-19 in the UK and internationally quickly established the factors associated with increased early mortality, including older age, greater co-morbidity and ethnicity. In general, increasing frailty is positively correlated with mortality independently to age.1 Less clear are the longer-term impacts of C-19 on patients including care needs, readmissions, recovery to baseline and lasting impact on function and quality of life.

Aim: to evaluate mortality rate, readmissions and residential status of patients 6-months after admission to hospital with C-19 Methods

Longitudinal evaluation of routinely collected patient data Inclusion criteria: Admissions to Northumbria Healthcare Trust during a 2-month period (28/02/20-27/04/20) Positive C-19 PCR test Level 1 care (Ward-based care, may require IV or oxygen by face mask, but does not require organ support) Data collected from electronic records and analysed at 3-months and 6-months after date of admission

Results at 3-months (n=360)

360 level 1 patients admitted in 2-month period Median age 78, median length of stay 9 days (range 1-90) Mortality rate 30% (108/360) Positive correlation between increasing clinical frailty score (cfs) and mortality (Figure 1) 16% of discharged patients (40/252) required increased care on discharge (transfer to residential or nursing care, or new care package)

Of 252 patients discharged, a further 35 (14%) had died overall mortality at 6-months 39.7% 95 patients (38%) required at least one readmission Of the 40 patients requiring increased care on discharge: 7 (18%) died 15 (38%) returned to their previous residential status 17 (43%) still required increased support

Conclusions

In keeping with previous studies,1 our sample had a high inpatient mortality rate (30%) which rose to 39.7% at 6-months More than one third of patients required at least 1 readmission within 6-months For patients discharged to a higher level of care than on admission (residential or nursing care, or a new care package at home), the majority did not return to their original residence Our findings can help inform discussions that clinicians have with patients and families about expectations following an admission with C-19.

Limitations and unresolved issues

How accurately is CFS score recorded in clinical practice? How does readmission and transfer to higher level of care impact on the quality of life of patients and families? How can we more accurately follow-up post C-19 patient outcomes using routinely collected data?

Key messages: Inpatient and 6-month mortality for C-19 is high Following an admission with C-19 there is a high risk of readmission For patients discharged with higher care needs, the majority do not return to their original residence by 6 months References: 1. British Geriatrics Society (2021). Covid-19: Frailty Scores and Covid-19 Outcomes. Available at: https://www.bgs.org.uk/covidfrailty Accessed March 2021

The influence of frailty on outcomes for older adults admitted to hospital with benign biliary disease: a single centre, observational cohort study Michael Thomas1, Minas Baltatzis1, Angeline Price2, Jenny Fox2, Lyndsay Pearce1, Arturo Vilches-Moraga2 of General Surgery, Salford Royal Foundation Trust, Salford, United Kingdom 2Geriatric Medicine Unit, Salford Royal Foundation Trust, Salford, United Kingdom

1Department

Introduction and aim

Methods Observational cohort study. Included patients aged 75 years and over admitted to surgical wards with a diagnosis of acute benign biliary disease. Data collection between 17/09/2014 and 20/03/2017. Patient demographics, Clinical Frailty Scale (CFS) score, levels of dependence on admission and discharge, interventions, inpatient complications, length of stay and mortality were recorded.

Results

Management

60 50 Patient count

The prevalence and complications of biliary disease increase with age. In older populations, across a range of clinical settings, research has demonstrated the influence of frailty on adverse outcomes. This includes the surgical setting. We describe the prevalence of frailty in older patients hospitalised with benign biliary disease and determine the influence of frailty on clinical outcomes and its association with mortality and duration of hospital stay.

104 patients received medical treatment only. Surgery was more common in non-frail (F 2% vs. NF 11%), percutaneous drainage more frequently carried out in frail patients (15% vs. NF 5%) and endoscopic cholangiopancreatography (ERCP) was similar in both groups (F 32%vs. NF 31%).

40 30 20 10 0

No intervention

CFS 1-4

Diagnosis

Cholecystostomy

ERCP

CFS 5-9

Frailty was associated with worse clinical outcomes in F vs. NF: functional deconditioning (34% vs. 11%), increased care level (19% vs 3%), length of stay (12 vs. 7 days), 90-day (8% vs. 3%) and 1 year-mortality (48% vs. 24%). Clinical Outcomes

200 patients were included. Acute cholecystitis was the most common diagnosis (43%) followed by acute cholangitis (36%) and acute pancreatitis (21%).

Surgery

Non-frail (CFS 1-4)

Frail (CFS 5-9)

P value

Hospital Acquired Pneumonia

16%

0.019

Delirium

15%

33%

0.005

Arrhythmia

17%

0.049

Median length of stay

7 days

12 days

0.003

Dependency at discharge

48%

<0.001

90 day mortality

0.134

12 month mortality

24%

48%

0.002

Conclusions

Cholecystitis

Cholangitis

Pancreatitis

Median age was 82 (75-99), 60% female, 89% lived in their homes, 154 (77%) were independent for personal and 99 (49.5%) for instrumental ADLs, 95% were independently mobile, 17.5% had memory impairment and 8% low mood. 99 patients were non-frail (NF = CFS 1-4) and 101 were frail (F= CFS 5).

Half of patients in our cohort of older adults hospitalised with benign biliary disease were frail. Frailty status was associated with increased risk of complications such as delirium and deconditioning Compared with non-frail patients, individuals living with frailty were less likely to undergo surgical treatment, spent longer in hospital and were less likely to remain alive at 12 months after hospital discharge. The study emphasises the importance of frailty identification in the emergency general surgical population, with a potential role for frailty teams in supporting the management of these patients.

Incorporating Comprehensive Geriatric Assessment into Amersham Community Hospital Clerking A Quality Improvement Project

Dr Anastasia Oates, supervised by Dr Beatrix Nagyova

Aim

To increase the number of patients receiving a Comprehensive Geriatric Assessment at Amersham Community Hospital by adapting the admission clerking pro forma and providing relevant education to junior doctors.

Background

NICE Quality Standard states that older adults with complex needs should have a Comprehensive Geriatric Assessment (CGA) on admission to hospital1. The existing clerking pro forma at Amersham Community Hospital omitted many elements of CGA, meaning that for many patients, this was not completed during their admission. Why does this matter? 62% of hospital bed days are occupied by adults aged over 65. The number of adults aged over 65 admitted to the Emergency Department rose by 18% from 2010-11 to 2014-152. Evidence has shown that CGA can reduce length of admission, and at 3-12 month follow-up patients are more likely to be alive in their own homes3.

Plan: to incorporate elements of CGA into the admission clerking pro forma and provide formal education for junior doctors.

Do: the adapted clerking pro forma was

implemented. Formal education was provided on the importance of a thorough CGA.

Study: admission clerking notes of the next

12 patients admitted using the new pro forma were audited, with the percentage of patients assessed for each element of CGA recorded.

Act: the clerking pro forma was adapted again using feedback from the team and to target elements of CGA which were still being neglected.

Element of CGA

Baseline

Sensory Loss Examination of Feet Gait, Balance & Posture Pain/Arthralgia LSBP Weight & MUST Score Frailty Score Accommodation Pre-morbid Function Care Provision Driving Status Falls History Continence Mood Capacity/Safeguarding Lasting Power of Attorney Cognition Medication Issues Creation of Problems List Investigations & FRAX Score Creation of a Care Plan

42 8 8 42 42 0 8 25 50 83 0 42 67 8 0 25 67 17 25 25 33

Patients Assessed (%) Cycle Cycle Cycle 1 2 3

50 58 42 33 42 42 75 50 58 83 67 75 75 83 33 25 83 58 83 67 75

92 83 67 42 42 67 92 92 83 100 92 83 100 83 83 58 100 75 100 75 75

67 83 67 50 92 75 83 100 67 100 75 83 83 83 58 58 92 67 83 92 67

Table 1: Demonstrating percentage of patients assessed for each element of CGA .

25 75 59 8 50 75 75 75 17 17 75 41 16 75 58 33 25 50 58 67 34

Incorporating CGA into the admission clerking pro forma and providing education for junior doctors leads to a more thorough CGA for community hospital patients. Conclusion

The adapted clerking pro forma, alongside relevant education for junior doctors resulted in improvement in the assessment of all selected elements of CGA. The clerking pro forma continues to be used at Amersham Community Hospital. Data will be recollected in 3-4 months to evaluate the long term impact of the change, and to guide further intervention.

References

1)NICE. (2016). Transition between inpatient hospital settings and community or care home settings for adults with social care needs. (https://www.nice.org.uk/guidance/qs136/chapter/Quality-statement-2Comprehensive-geriatric-assessment) 2)National Audit Office. (2017). Discharging older patients from hospital. (https://www.nao.org.uk/wp-content/uploads/2015/12/Dischargingolder-patients-from-hospital.pdf) 3)Ellis et al. (2017). Comprehensive geriatric assessment for older adults admitted to hospital. (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD00621 1.pub3/full) 4)BGS (2019). CGA Toolkit for Primary Care Practitioners (https://us02web.zoom.us/j/86845236221?pwd=aGJ0akRGN2o0dT RSNCtSSGpoRy96QT09)

Scan QR code below for full report.

Laxative Bundles: The key to preventing inpatient constipation? Title: Subtitle Leeroy Jenkins, author2, author3, author4

Everyone Needs to Poop: Reducing constipation in the elderly inpatient population. JCRG Rollo-Walker Background Due to a variety of physiological and pathological factors the elderly population are prone to constipation. This is exacerbated in hospital and can impact the entire admission increasing morbidity and mortality for what is a treatable problem. Objective To identify factors causing constipation in the inpatient population and test possible solutions. Method 1. Nursing handover sheets collects over period of 15 days across 3 wards (up to 87 patients) 2. Date bowels last opened recorded. Constipated if >3 days. 3. 2 days selected and common themes in constipated patients analysed and drug charts reviewed 4. Stakeholders surveyed (Prescribers, nursing staff, patients, Consultants)

Intervention and Results Senior Nurses to highlight constipated patients at morning MDT Covid-19 outbreaks on all wards meant regular staff off sick and intervention failed Laxative Bundle added for e-prescribing. - No significant drop in constipation - 32% patients (23/72) had bundle prescribed - 22% patient still had no aperients prescribed. Aperient prescribing guide written Discussion Bundle has not resulted in more patients being prescribed aperients but has led to increased choice for patients/nursing staff Covid-19 and staff turnover have meant changes did not have full impact Prescribing guide needs to be more accessible System based intervention is more successful than person dependent. Falls team keen to promote due to link with inpatient falls. Prescribing bundle and advice document allows for the opportunity of sustained change Looking Forward Plan to add prescribing advice to bundle to make it more accessible. Investigate the relationship between establish if a department wide change in management is needed

Many thanks to Dr Tom Bartlett for advice and help with this project .

Added information Initial Findings Approximately 27% patients constipated on average at any one time. The majority (up to 100%) classed as Medically Ready to leave hospital. 25% patients had no aperients prescribed Nurses felt they were sometimes unable to give aperients when they wanted to as not prescribed Prescribers unsure of best option/combination Patients felt unable to take usual aperients. Consultants felt PRN aperients should be readily available to all patients Laxative Bundle added

Draft guidelines

CIRS-G

MDAS SODS Abbey and PAINAD

SMEOLD

Clinical Dementia Rating Environment

CMAI

NPI

Caring For and Caring About Older People Living with Severe Frailty During Covid-19 Richard Green1, Helen King2, and Caroline Nicholson1,2. 1University of Surrey, 2 Background The ongoing PALLUP study has collected qualitative survey and interview data from older people living with severe frailty living in the community in the last years of life during the Covid-19 pandemic. Data has been collected to better understand the needs of this population near end of life.

Methods Participant-led video interviews with older people with severe frailty living in the community (N=10), which included accounts from unpaid carers (N=5), were undertaken between October-November 2021. Seven of these older people have died since fieldwork completion. A face-toface survey collected data from a further 10 older people. Participants ages ranged from 70-99, 11, men, and 9 women, living in owned, rented, or sheltered accommodation, with Clinical Frailty Scores of 6 (N=8), 7 (N=9), and 8 (N=3).

Results Common topics raised in relation to the pandemic included loss of social contact, increased loneliness, concern about not physically getting out, and losing physical function.

Older people struggled to gain access to health and social care for support and previously received services were withdrawn.

Challenges for fieldwork of internet access. They relied heavily on families to facilitate virtual contact with health professionals.

This research draws on an innovative, flexible design where only by on-site clinician facilitation and technology provision were these interviews made possible.

conditions worsened family provided intense support, though family carers described the strain and unsustainability of this provision.

Older people and their families felt they had been forgotten.

Families and friends were the main anchor in facilitating social and health care, including chasing up medications, liaising with social care to ensure quality and consistency of care provided, and monitoring

This study is funded by the National Institute for Health Research (NIHR) [HEE/NIHR ICA Programme Senior Clinical Fellowship (ICA-SCL-2018-04ST2-001)]. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Conclusions These are insights from an under researched population that are frequently invisible. Covid-19 has exacerbated the challenges of both meeting the needs of this group and undertaking research to better understand these needs. For this group, services are needs to be met but also allow them to be heard and recognised first.

Implications for Practice Greater examination of the impact of using communication technologies in care provision for this population is required. Unpaid carers need more information and resources to support the care they provide and to facilitate access to appropriate social and health care services for those they care for. Next Steps The next phase of the PALLUP study will involve an Englandwide survey to determine how community services are currently responding to this needs. Correspondence: richard.green@surrey.ac.uk Twitter: @ThePALLUPstudy

Readmissions to Geriatric Medicine in a District General Hospital, a Thematic Analysis in collaboration with the Acute Frailty Network. Dr Rebecca Whiting, Consultant Geriatrician Renee Comerford, Nurse Consultant for Older People and Head of the Acute Frailty Service Charlotte Bowdell, Frailty Services Matron

Introduction The readmission of elderly patients is widely recognised to have negative implications both to service, in terms of capacity and cost but also, more importantly in terms of patient experience, morbidity and mortality. 621 patients were readmitted within 30 days of discharge from our Geriatric Medicine department between October 2019 and March 2020. This project was undertaken to search for trends within this data, look more deeply into these cases, and better understand whether some of these readmissions could be prevented.

Methods Readmissions from our department were plotted against days following discharge. Analysis showed a clear peak at day one post discharge. (Fig1) In light of this trend a subsequent Pareto analysis revealed that nearly 80% of these were discharged from 2 locations, our frailty unit and MAU. (Fig2) This cohort therefore became the focus of our review. In June 2020 in collaboration with the Acute Frailty Network, a virtual structured case note review was undertaken by a multidisciplinary team including an independent Geriatrician. Permission from Information Governance was obtained and the patients electronic case file records were reviewed against an agreed proforma.

Future Plans A culture survey regarding delirium has been performed and a multidisciplinary quality improvement group looking at delirium initiated. The group, co-led by Dr Emma Drydon had the following primary aims: 1. Increase the use of 4AT for Frailty Patient Group to 80% within 6 months and 95% in 12 months. 2. To increase diagnosis rate of delirium from 4% (median diagnosis over the last 2 yrs) to 20% in keeping with national expectations3 within 6 months. 3. To increase the elements of PINCHME mnemonic4 documented for patients with a diagnosis of delirium within the acute frailty patient group on AMU to 60% within 6 months. After several interventions including prompt cards and a training programme, a statistically significant improvement in the use of 4AT has already been reached. A further review of readmission data with case note review is planned to identify focus points for future work.

The correct healthcare spell was located, and a clinical assessment of the case file was undertaken in depth. This considered whether the patient was readmitted with a new diagnosis and whether improvements to the discharge process could have prevented readmission. All cases were reviewed to see whether a Clinical Frailty Score was recorded, and when and by whom Comprehensive Geriatric Assessment was commenced. Finally the case was reviewed to ascertain whether any service level improvements could have prevented readmission.

Fig 1

Results The case note review process was halted early as clear recurring themes emerged. Firstly, feedback showed that all frail patients were identified early in the patient pathway, were cared for by the appropriate team and a CGA was commenced promptly. This occurred in every patient reviewed and served as reassurance that our current pathway was effective in that regard.

Fig 2

Qualitative data regarding patient care was also noted to feed forward to clinical teams. (Fig3) Secondly, it was clear that the overwhelming majority of day one readmissions had a diagnosis of delirium. For the majority of patients this diagnosis was made at reattendance rather than during their index admission. With retrospect, all such patients had symptoms and signs of delirium documented in their clinical case notes, but there was a failure to acknowledge this and formally reach a diagnosis. There were zero documented 4AT scores (a short delirium assessment tool that has been widely validated for use in elderly inpatients is the 4AT. 1 & 2) in any case notes reviewed. It was felt by both the independent reviewer and the internal team that this failure to diagnose, label and therefore treat delirium accordingly meant that discharge planning failed to properly consider fluctuations in cognition associated with delirium and contributed to a high 1 day readmission rate.

Conclusion We found that delirium identification was a clear key factor in early readmissions to our service. We identified clear opportunities to strengthen and formalise delirium diagnoses, take more careful cognition histories and ensure that deeper conversations were consistently held with carers and patient family members. It was felt that this would not only improve inpatient diagnosis, management, communication and care for patients with delirium but strengthen the discharge process and hopefully reduce early readmissions.

Med Ill ref: 117000/21

Fig 3

References 1. MacLullich A, Ryan T, Cash H (2014) 4AT: Rapid Clinical Test for Delirium. Version 1.2. www.the4at. Com (last accessed 15/04/21) 2. Shenkin SD, Fox C, Godfrey M, Siddiqi N, Goodacre S, Young J, Anand A, Gray A, Hanley J, MacRaild A, Steven J, Black PL, Tieges Z, Boyd J, Stephen J, Weir CJ, MacLullich AMJ. Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the Confusion Assessment Method. BMC Med. 2019 Jul 24;17(1):13 3. Geriatric Medicine Research Collaborative. Delirium is prevalent in older hospital inpatients and associated with adverse outcomes: results of a prospective multicentre study on World Delirium Awareness Day BMC Medicine (2019) 17:229 4. Dixon M (2018) Assessment and management of older patients with delirium in acute settings. Nursing Older People. doi: 10.7748/nop.2018.e969

With thanks to: Emma Blackhouse (Head of Improvement Networks, NHS Elect), Professor Simon Conroy (Clinical Lead of Acute and Specialised Frailty Networks, NHS Elect), Dr Emma Drydon, (Consultant Geriatric, CHFT), Alasdair Finn (Performance and Information Lead, CHFT), Simon Griffiths (Director, NHS Elect) and Matthew Tite (Director of Measurement, NHS Elect).

Age, Frailty and Comorbidity in COVID-19 Inpatients 65 and Older Nonyelum Obiechina, Atef Michael, Rana Rashid Ali Khan, Meithem Ali, Muhammad Zainudin, Tarunika Mekala, Ciara-Marie Doyle, Angela Nandi

University Hospitals of Derby and Burton NHS Foundation Trust

Results

Background Higher incidence of COVID-19 and poorer outcomes have been shown to be associated with age, frailty and comorbidity. Older people have more risk of severe COVID 19; hospitalization, ITU admission, ventilation and mortality.

and Dudley Group NHS Hospitals Trust

•

357 COVID-19 patients 65 and over were assessed; 207 males and 150 females.

•

Mean age was 81.9 +/- 9.31.

•

Frailty scores were measured using the Rockwood Clinical Frailty Scale (CFS) and comorbidity was calculated using the Charlson Comorbidity Index (CCI).

•

There was positive correlation between age and Clinical Frailty Scale (r=. 436; p<. 001), between age and Charlson Comorbidity Index (r=. 448; p<. 001, and between frailty and comorbidity (r=. 429; p<. 001

Results

Objectives

Method Design A retrospective, cross-sectional analysis was carried out on COVID 19 inpatients 65 and older in a UK district general hospital. Patients with no microbiological evidence of COVID-19 and patients with incomplete data were excluded from the study. Demographic data, frailty score and comorbidity index were extracted from the electronic records of patients. Statistical Analysis SPSS 27 statistical software was used to perform descriptive analysis and linear regression coefficient.

Conclusions C

References In COVID-19 inpatients 65 and older, there was positive correlation between age and Clinical Frailty Scale, between age and Charlson Comorbidity Index and between frailty and comorbidity. More studies are needed to explore the interaction between age, frailty and comorbidity and COVID 19 morbidity and mortality.

No conflict of interest. Retrospective analysis of anonymous data- did not require ethical approval.

Improving Content in Discharge Summaries for Coding Dr C Alcock, Dr P Oluwamayowa, Ms E Wallace, Dr K Honney

Hospital coding provides a pivotal service, integral to data collection, national statistics and hospital finances. The system of accurately coding depends almost entirely on the information put into Electronic Discharge Letters (EDLs). This project aims to up skill doctors with the expertise of the coding department, so that the EDLs reflect more accurately the experiences of the patient in hospital. Cycle 1 Invite Clinical Coding to the ward Doctors and Coders write EDLs together Measure revenue over time

Cycle 2 Doctor and Coder review EDLs from the Ambulatory Emergency Clinic (AEC) Measure increase in code values EDLs had co-morbidities added

75% 42% EDLs undervalued cost of £757 Average undervalued EDL Potential addition £218,271 revenue in one month Result: No Improvement Too heterogenous Coding reviewed ward EDLs routinely

Results: Large Financial benefit Clinically relevant Co-morbidities added Improved record keeping Average 5 mins spent per EDL

The role of the physician cannot increase indefinitely, and there is a wealth of knowledge and experience to be gained from our colleagues in the coding department. This collaboration in assiduously improving the service that our patients receive brings the possibility of large financial gains as well as more accurate health care records

Reference: Additional poster material from www.freepik.com/photos/background

Easing the Strain of Constipation in Care Homes Fiona Kirkpatrick - Lead Case Management Pharmacist for Care Homes. Medicines Optimisation in Older People (MOOP) Team, Belfast HSC Trust

Introduction

Constipation has consistently been found to be a common disorder across the world and has a significant impact on quality of life (Belinni et al1, 2017). A recent study (Lindberg et al 2, 2010) showed that the elderly patient population find constipation to be a significant health problem. Older individuals are particularly prone to constipation with a reported prevalence of up 50% for those living in community with the prevalence rising to 70% within nursing homes (De Giorgio et al3, 2015). A recent study Mounsey et al 4 (2015) detailed that constipation is diagnosed taking account of symptoms of incomplete elimination of stools including difficulty passing stools, hard stools, abdominal bloating, pain and distention.

Figure 1: Guide for the stepwise approach to laxative use in Care Homes

Objectives

To assess impact of staff education & pharmacist intervention on appropriateness of laxative use:

Staff education

Examine the baseline knowledge of care home staff on constipation and laxative use Formulate an education package to deliver to care home staff on key aspects of laxative use Critically evaluate the staff knowledge post the educational intervention.

Impact of pharmacist medication review on laxative use

Critically evaluate the impact of pharmacist review on appropriateness of laxative use in care Homes

Staff Education:

The baseline knowledge of care home staff was examined using the same questionnaire, pre- and post-educational intervention on key aspects of laxative use. Staff directly administering medication or directly impacting on care in each of the three care homes were included. An education package for delivery in nursing homes was designed and implemented to cover the key aspects of laxative use . A guide (Figure 1)5,6,7,8 was created to educate staff how to follow a stepwise individualised approach for the treatment of constipation.

Impact of Pharmacist medication review on laxative use:

Thirty kardexes were retrospectively examined for prescription of multiple laxatives from the same group as an indicator of inappropriate laxative use, pre and post pharmacist intervention.

Results

Pre education

Staff Education

Thirty three staff completed the questionnaires. The educational package developed on laxative use was found to have a positive impact on the knowledge of the staff on constipation and laxative use (Figure 2) with statistically significant improvements in staff knowledge post education, with p-value <0.05. Healthcare mean percentage increase in knowledge following education mirrored that of nursing staff at almost 50%.

Impact of Pharmacist medication review on laxative use:

There was a statistically significant improvement in appropriateness of laxative prescribing following the pharmacist led medication review of 30 residents. 46% fewer patients were prescribed laxatives inappropriately from the same class following medication reviews with a p value of 0.00002, the result is significant at p < .05.

% change in staff knowledge

Method

Three BHSCT Care Homes being case managed by the Medicines Optimisation Pharmacist were included in the study.

Post education

100.0 50.0 0.0

Figure 2: Overall % change in staff knowledge pre- and post education

Discussion

The positive impact of this study supports the conclusion by Chen et al 9 (2014) that patient and carer education should be first line treatment for non-severe constipation. Shen Q et al10 (2018) also suggested that educational intervention for patients can effectively improve constipation symptoms, treatment and result in improved health habits however this study provides further evidence that the education of care home staff plays a significant role in improving the appropriate management of constipation for care home residents. Pharmacist-led review of laxatives has the potential to improve a Care Home quality of life, as previously suggested by Dennison et al11 (2005), with the potential to reduce the risk of complications or hospital admissions from ineffective treatment of chronic constipation. The significant improvement in appropriateness of laxative prescribing following pharmacist review is not unexpected as pharmacists provide expert analysis of medication appropriateness.

Conclusion

rrent laxatives regimes resulted in a statistically improved appropriateness in laxative use. The education package developed will be shared with Medicines Optimisation for Older People (MOOP) Care Home Pharmacists for delivery in NI trusts. Future work would include aiming for trust approval to use and circulate the laxative use guide (Figure 1)5,6,7,8 and adapt the current education package into an online format. References

1. Bellini M. et al ChroCoDiTE Study Group. AIGO (2017). Chronic constipation diagnosis and treatment evaluation: the "CHRO.CO.DI.T.E." study. BMC Gastroenterology, 17(1), 11. 2. Lindberg G. et al 2010. World Gastroenterology Organisation Global Guideline: Constipation-a Global Perspective. J Clin Gastroenterol, Jul; 45(6), 483-7. 3. De Giorgio et al 2015. Chronic constipation in the elderly: a primer for gastroenterologist. BMC Gastroenterology, 14:130. 4. Mounsey A. et al. 2015. Management of Constipation in Older Adults. American Academy of Family Physicians, 92 (6), 500-504 5. COMPASS (2016) Therapeutic Notes on the Management of Chronic Constipation in Primary Care. Northern Ireland Centre for Pharmacy Learning and Development. 6. Health & Social Care Board Northern Ireland Formulary Gastrointestinal: Laxatives. [ONLINE] Available at http://niformulary.hsni.net/Formulary/Adult/PDF/Chapter%20summaries/Chapter1_GI_Summary.pdf [Accessed on 12 March 2018] 7. Joint Formulary Committee. British National Formulary (online) London. 2018. Constipation Treatment Summaries.[ONLINE] Available at: https://www.formularycomplete.com/view/treatmentsummary/monograph/26726. [Accessed 10 March 2018]. 8. McSorley R. et al (2016). Guidance for the Use of Laxatives in Older People, Western Health and Social Care Trust. 9. Chen I. C. et al (2014). Prevalence and effectiveness of laxative use among elderly residents in a regional hospital affiliated nursing home in Hsinchu County. Nursing and Midwifery Studies, 3(1), e13962. 10. Shen Q et al (2018) Nurse-Led Self-Management Educational Intervention Improves Symptoms of Patients With Functional Constipation. West J Nurs Res. 2018 Jun;40(6):874-888 11. Dennison et al (2005) The Health-Related Quality of Life and Economic Burden of Constipation. Pharmacoeconomics,23 (5), 461-476.

Differences between waves 1 and 2 in baseline characteristics and survival of patients hospitalised with COVID-19. The Salford experience. 1

Amarah Khan , Fernanda Ramon Espinoza , Thomas Kneen , Anna Dafnis , Hala Allafi , Ben Carter , 1 2 1 1 1 Maria Narro-Vidal , Roxanna Short , Angeline Price , Rebecca Upton , Arturo Vilches-Moraga 1

Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience King's College London

Introduction & Aims

Results (cont.) Figure 2: Time to mortality by wave

In March 2020, the World Health Organisation declared a global pandemic due COVID-191. The first wave of the COVID-19 pandemic resulted in an unprecedented public health crisis, with an overwhelming impact on healthcare systems. Following the first wave, there were a number of studies looking at the characteristics of patients hospitalised with COVID-192 3. There is little evidence comparing the first and second waves of the pandemic. We aim to compare baseline characteristics and survival of patients hospitalised with COVID-19 in the first and second waves.

Methods Prospective observational study of all consecutive patients admitted to Salford Royal Hospital between 27th February and 28th of April 2020 (wave 1), and 1st October to 10th November 2020 (wave 2) with a diagnosis of COVID-19. Patient demographics, co-morbidities (diabetes, hypertension, coronary artery disease), biochemical parameters (CRP and eGFR), lifestyle factors (smoking) and frailty using the Clinical Frailty Scale (CFS) were collected. Analysis: Logistic regression associating patient characteristics with wave; Cox proportional hazards model associating wave and patient characteristics with mortality (time to mortality). Both models fully adjusted for patient characteristics . Kaplan-Meier

effect of Wave on time to mortality.

Age; sex; smoking status; hypertension; diabetes; kidney function (eGFR); coronary artery disease; CRP.

Discussion

Results Wave 1 patients: N=429 (42% female); median age 72; N=160 deaths (37%); N=212 (49%) frail (CFS 5-9).

Baseline characteristics were similar in both waves of hospitalised patients with COVID-19.

Wave 2 patients: N=271 (38% female); median age 73; N=80 deaths (30%); N=106 (39%) frail.

Patients were more frail in wave 1.

Baseline age, sex, smoking status, diabetes presence, CAD, and kidney function were similar in waves 1 and 2 (Fig. 1). Patients were more frail in wave 1 (Fig. 1). CRP higher in Wave 1; Wave 2 patients more likely to have hypertension (Fig. 1). Significant reduction in mortality in Wave 2: aHR=0.71 (95% CI 0.53-0.94) (Fig. 2).

Figure 1: aOR for baseline characteristics in wave 1 vs wave 2

There was a significant reduction in overall mortality in the second wave. There are a number of factors which could explain the reduced mortality in the second wave. This may in part be due to the increased clinician experience and familiarity with COVID-19 in the second wave. It may also be representative of the emerging evidence base and research into therapies for this novel disease. In addition, the patients admitted in wave 2 were less frail, which may have been a protective factor. This data was collected from a single site. There is a need for further research, particularly a multicentre study, comparing both waves of the pandemic.

References 1.

World Health Organisation. COVID-19 Weekly Epidemiological Update: Available online: https://www.who.int/dg/speeches/detail/who-directorgeneral-s-opening-remarks-at-themediabriefing (accessed 24/03/2021)

Hewitt J, Carter B, Vilches-Moraga A, Quinn TJ, Braude P, Verduri A, Pearce L, Stechman M, Short R, Price A, Collins JT. The effect of frailty on survival in patients with COVID-19 (COPE): a multicentre, European, observational cohort study. The Lancet Public Health. 2020 Aug 1;5(8):e444-51.

Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L, Holden KA, Read JM, Dondelinger F, Carson G, Merson L. Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study. bmj. 2020 May 22;369.

Delirium Screening Quality Improvement Project Dr Salam Al-Alousi, Chief Registrar RCP, Acute & General Internal Medicine Registrar Dr Asad Ullah Khan, Trust Grade Doctor; Dr Emily Laithwaite, Consultant in Geriatric Medicine University Hospitals of Leicester NHS Trust

Figure 1 UHL Dementia & Delirium Screening Tool in the Universal Clerking Proforma

INTRODUCTION Delirium is a common neuropsychiatric syndrome in patients over the age of 65 presenting to medical admissions units yet remains under-diagnosed despite significant associated mortality and morbidity. Our delirium screening tool (Fig 1) incorporates a four-step approach, with completion of validated 4AT test warranted in all those over 65 years of age admitted with increased confusion or are more withdrawn. Our aim was to measure current uptake of this delirium screening and introduce measures to improve practice. METHOD We retrospectively collected data from medical records of patients on two Geriatric inpatient wards (42 patients) at the Leicester Royal Infirmary, to determine whether appropriate delirium screening was taking place for atrisk patients on admission. We then introduced two PDSA (plan, do, study, act) cycles (details shown below).

Sex

Known Cognitive Impairment/Dementia

Female 45%

Male 55%

No 50%

4AT Completed in Patients Diagnosed with Delirium

Yes 50%

Average Age: 82.3 4AT Completed?

No 18 95%

Abbreviated Mental Test (AMT) Completed? Yes 5%

No 98%

1ST

Yes 1 5%

Yes 2% No 95%

SEPTEMBER 2019

1 ST PDSA CYCLE

BASELINE AUDIT

A third cycle was planned involving visiting wards to raise awareness, however this was interrupted by the COVID pandemic.

Teaching at weekly departmental meetings, in Acute Medicine and Geriatric Medicine, using PowerPoint presentation. The importance of delirium detection, and its effect on morbidity and mortality were emphasised.

Known Cognitive Impairment/Dementia

Sex Male 37% Female 63%

Yes 37%

Average Age: 84.2 Abbreviated Mental Test (AMT) Completed?

4AT Completed?

2 ND PDSA CYCLE

Yes 6%

Female 55%

Known Cognitive Impairment/Dementia Male 45%

4AT Completed in Patients Diagnosed with Delirium

Yes 35%

No 20 87%

No 63%

No 94%

Sex

4AT Completed in Patients Diagnosed with Delirium

Yes 16% No 84%

Yes 3 13% June 2020

No 10 56%

No 65%

Average Age: 82.3 Abbreviated Mental Test (AMT) Completed?

4AT Completed? No 84%

Creation of a poster to remind

Yes 14% Yes 16%

No 86%

Yes 8 44%

2ND

when seeing patients. This was displayed on the wall of all admission units in Medicine.

NOVEMBER 2020

RESULTS Initial baseline results showed only 5% (1 of 18) of at-risk patients were appropriately screened. Following our first intervention, this increased to 13% (3 of 23). Second intervention involving display of posters led to an increase to 44% (8 of 18). Proportion of patients with a diagnosis of dementia were comparable across PDSA cycles. Contact: salam.al-alousi@uhl-tr.nhs.uk

CONCLUSIONS Education, raising awareness, and display of reminder posters can improve delirium screening uptake of at-risk patients on admission to medical admission units, despite growing pressures associated with the COVID pandemic. Further interventions are planned to improve and maintain awareness and uptake of delirium screening.

Establishing virtual multidisciplinary rounds in Belfast Trust Nursing Homes: Pharmacist, nursing & healthcare team collaboration Fiona Kirkpatrick - Lead Case Management Pharmacist for Care Homes, Paula Crawford consultant Pharmacist Older People, Oonagh Galway Care Home Nursing Support Team, Rema Wilson Care Home Nursing Support Team, Monique Kritzinger - Dietician, Deborah Gray Speech & Language Therapist, Elaine Gowdy Occupational Therapist, Emma Christie - Physiotherapist

Introduction:

During the covid pandemic, Trust Care Homes had limited face to face access for healthcare professionals. Nursing home residents required medicine reviews post-covid infection to optimise medicines and reduce pill burden. The Department of 1 Enhanced Framework for Clinical & Medical input to Care Homes highlights the high level of frailty & clinical acuity of nursing home residents & need for multidisciplinary clinical reviews & partnership working. Virtual multidisciplinary rounds were established to facilitate clinical review of residents.

Method:

The Care Home Nursing Support Team (CHNST), consultant pharmacist for older people and the lead care home pharmacist medicines optimisation older people(MOOP), established a multidisciplinary (MDT) virtual round (Figure 1) guided by national standards for MDT modern ward rounds2 including: Establishing a Standard Operating Procedure (SOP) Electronic pro forma template design by pharmacist (Figure 2) for completion by the nursing home staff to gather key information ahead of the round to improve efficiency e.g. swallow, renal function, pain, falls Evaluation of service The inclusion group included residents furthest from baseline post covid infection, e.g. weight, swallowing difficulties, mobility, altered sitting balance & polypharmacy.

Figure 2: Snapshot of eProforma to plan ahead for virtual MDT round:

Results & Discussion:

Figure 3 highlights there was an average of 4.1 recommendations per resident from MDT as a whole, & 2.9 pharmacy interventions per resident with majority EADON grading level 4 or 5. Grade 4= Intervention is significant and results in an improvement in the standard of care e.g.. requesting lab tests. Grade 5= Intervention is very significant and prevents a major organ failure or adverse reaction e.g. nephrotoxic medication dose reductions/medication stopped or anticoagulant dose optimised The Medicines Appropriateness Index (MAI) measures potentially inappropriate prescribing & decreased for all residents following pharmacist intervention, indicating inappropriate prescribing. Evaluation of the service: 96% respondents (Care home staff & MDT) strongly agreed or agreed that the collaborative approach of MDT and care home staff on one call was an efficient use of time & were keen for the virtual MDT service to continue. Figure 3: Statistics & outcomes of MDT virtual care home rounds

Figure 1: Pharmacist, AHP, nursing(CHNST), care home & medical team on MDT virtual round

Conclusion:

The multidisciplinary virtual care home rounds provided an efficient means to collaborate with other professionals, while providing holistic & patient-focused care in line with national guidance on modern ward rounds 2. They demonstrate efficiency More Silos1

References: 1. No More Silos: Covid 19 Urgent & Emergency Care Action Plan. Enhanced Framework for Care Homes. Department of Health 2020 https://www.healthni.gov.uk/sites/default/files/publications/health/doh-no-more-silos 2. Modern Ward Rounds: Good Practice for Multidisciplinary Inpatient Review Royal College of Physicians 2021 ISBN 978-1-86016-843-7

Management of Severe Orthostatic Hypotension Associated with Supine Hypertension in a Patient with Autonomic Dysfunction on Background of Metastatic Nasopharyngeal Carcinoma and Type II Diabetes Mellitus Ng QM Rachel, Arifin T. Department of Geriatric Medicine, Singapore General Hospital, Singapore

A 71-year-old man with metastatic nasopharyngeal carcinoma status post radiation therapy was admitted with severe supine hypertension-orthostatic hypotension. The patient was managed with both non-pharmacological and pharmacological methods, and monitored for postural symptoms, as well as complications of severe supine hypertension, which has been linked to left ventricular hypertrophy and kidney dysfunction. He was placed on 24-hour ambulatory blood pressure monitoring to aid in management so as to prevent hypertension induced organ damage. Patient s symptoms of postural hypotension improved and supine hypertension was well controlled. This case report summarizes the management of severe orthostatic hypotension and supine hypertension, using both non-pharmacological and pharmacological methods and the mechanism behind them.

Supine hypertension-Orthostatic hypotension is a form of autonomic dysfunction characterized by systolic blood pressure of at least 150 mmHg and diastolic blood pressure of at least 90 mmHg when supine, and a clinically significant drop in systolic blood pressure by at least 20 mmHg or reduction in diastolic blood pressure by at least 10 mmHg within 3 min of assuming an upright posture. There are many types of autonomic dysfunction, more commonly those with autonomic neuropathy from medications, injury (i.e. post radiation, chemotherapy or surgery) or disease. Diabetes would cause this neuropathy.

Figure 2. 24-hour ambulatory blood pressure and heart rate monitoring results of this elderly gentleman, who was on fludrocortisone 0.1mg OM and night transdermal GTN patch 0.2mg/hr from 2000 hours to 0600hours the next morning.

Combined chemotherapy and radiotherapy increase long term survival in patients with nasopharyngeal carcinoma. However, radiotherapy of the carotid sinus or brain stem can lead to labile hypertension and orthostatic intolerance from chronic baroreflex failure. Baroreflex is one of the most important mechanisms for short term blood pressure homeostasis2. A study by Sharabi et al showed that chronic baroreceptor reflex failure can be due to radiation induced accelerated development of carotid atherosclerosis, since splinting of carotid sinus mechanoreceptors in a rigid arterial walls would impede detection of alterations in blood pressure3. This can lead to disruption of baroflex regulation of cardiovagal and sympathetic outflow. Patients with baroreflex failure typically presents with postural lightheadedness, orthostatic hypotension, syncope and labile hypertension. Baroreflex failure is part of the spectrum of autonomic dysfunction that presents with tachycardia, systolic and diastolic hypertensive episodes, hypotension alternating with relative bradycardia at rest3.

Figure 1. Timeline of patient s medical issues and management.

Autonomic dysfunction due to baroreceptor failure was made based on the clinical picture of severe orthostatic hypotension with significant supine hypertension and the history of neck radiation and it is likely contributed by chronic diabetes mellitus. Patient was managed using table 1.

Baroreflex dysfunction is a relatively rare disorder; Surgery or radiotherapy of the carotid sinus or brainstem can result in acute or subacute baroreflex failure1-2. In this case, chronic baroreflex failure appeared to develop as a late sequela of neck irradiation for naso-pharyngeal carcinoma, due to accelerated atherosclerosis in the region of the carotid sinus baroreceptor. Seeing patients who suffered from this condition provide a learning opportunity to understand the role of the autonomic nervous system in controlling blood pressure. However, these patients can simultaneously develop other blood pressure regulation disorders such as supine hypertension and postprandial hypotension. Treatment of these conditions is required to achieve adequate control of pre-syncopal symptoms and prevent long term complications. Non-pharmacological interventions remain the first line of therapy. When these approaches are inadequate, pharmacological interventions are necessary, though it is crucial to understand the pathophysiology of these disorders to provide appropriate treatment for these patients. Nonetheless, management of blood pressure in these elderly patients with baroreflex dysfunction remains challenging and should be individualized. Moving forward, a prospective study about the incidence of late onset, iatrogenic baroreflex failure as a complication of neck irradiation and its particular relationship to carotid arterial rigidification should be conducted to increase awareness, timely diagnosis and management of the condition among physicians.

1. Shibao C, Okamoto L, Biaggioni I. Pharmacotherapy of autonomic failure. Pharmacol Ther. 2012;134(3):279-286. doi:10.1016/j.pharmthera.2011.05.009 2. Shapiro MH1, Ruiz-Ramon P, Fainman C et al. Light-headedness and defective cardiovascular reflexes after neck radiotherapy. Hypertension 2003; 42 (1): 110-6. 3. Sharabi Y, Dendi R, Holmes C, Goldstein DS. Baroreflex failure as a late sequela of neck irradiation. Hypertension. Hypertension. 2003;42 (1):110 116