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1.
BMJ Leader ; 5:A28, 2021.
Article in English | EMBASE | ID: covidwho-1968367

ABSTRACT

Aim NICE COVID-19 guidelines NG191 recognise that frailer patients, including those with a higher Rockwood Clinical Frailty Scale1 (CFS), are seldom improved by hospital admission. The project used a collaborative approach to undertake frailty reviews, aiming to reduce inappropriate hospital admissions. The reviews included discussing residents' preferred place of care and options in the event of deterioration, a Treatment Escalation Plan (TEP). Method A collaborative was formed between care home managers, pharmacists and geriatricians to review frailty factors in residents over 65 years, excluding those with Learning Disabilities. Care homes with high risk of COVID-19 were prioritised. A Standard Operational Procedure was approved within one month. Using existing resources only, the project was delivered over 3 months. Communication was sent to GP practices, care homes and residents/families and consent was obtained. Templates were developed and education delivered. Results Review outcomes were recorded electronically onto the GP clinical system. Care homes kept a copy and informed residents/ families of the outcome. 595 residents were reviewed in 21 care homes. Preliminary analysis for 71 residents reviewed May 2020 to April 2021 show: • 42 survivors, 33 with severe frailty (CFS 7-9), 9 not severely frail (CFS<7). Out of total 28 residents with TEP indicating avoidance of hospital admission, 23 were not admitted and 5 had single hospital admission. 14 residents TEP included hospital management of whom 7 were admitted. • 26 of the 29 deceased residents were severely frail. 96% died in their preferred place of death. Conclusion Clinical leadership demonstrated courage and capacity to challenge the status quo, improve organisational processes and innovate practice. This helped staff morale at a difficult time of immense pressure and positively enhanced care homes' profile and residents' experience.

2.
Epidemiology ; 70(SUPPL 1):S270, 2022.
Article in English | EMBASE | ID: covidwho-1853979

ABSTRACT

Background: This case describes the circumstances of an older woman and her daughter faced with the dilemma of whether or not to receive the COVID-19 vaccine at the end of life. Methods: Ms. V was a 90-year-old woman with past medical history of major neurocognitive disorder, asthma, and hypertension on home hospice after experiencing a rapid decline beginning in November 2020. By January 2021, she had significantly deteriorated with a prognosis of weeks. At this time, the COVID-19 vaccine had become available to high-risk individuals and their household members. Because Ms. V lacked capacity to make her medical decisions, her daughter and healthcare power of attorney, Ms. B, had to determine her wishes. Ms. V's goals were comfort care and to avoid hospitalization. Although she had worked as a nurse, she had declined her annual influenza vaccine in the past. However, Ms. B felt that her mother would have wanted to help her children and caretakers get the vaccine, which would only be possible if she got the vaccine first. Results: Extensive conversations with Ms. V's children, hospice team, and geriatrician were held utilizing the 4-box approach to ethical decision making.1 Ms. B decided that her mother would have wanted to receive the vaccine for the main purpose of also vaccinating her children, who both had advanced heart failure and were at high risk for complications from COVID-19. She received one dose of the Pfizer COVID-19 vaccine and died ten days later. Her children and live-in caregiver all received the Pfizer Covid-19. Conclusion: Although Ms. V had previously refused annual influenza vaccinations, her daughter felt that her mother would have gotten the vaccine to provide protection for her children and caregiver. While it was acknowledged that Ms. V would probably gather little immunity benefit from the vaccine due to her poor prognosis, her daughter felt that the benefits of the entire household receiving the vaccine outweighed any potential risks. Her family called this final act of protection her dying wish.

3.
Geriatric Orthopaedic Surgery and Rehabilitation ; 12:55-56, 2021.
Article in English | EMBASE | ID: covidwho-1817123

ABSTRACT

Introduction: Falls are a major health problem in older adults, leading to serious injuries and burdening their quality of life and functionality. Social isolation is predictive of falls, so a need for effective distance interventions is of great importance in this vulnerable population. Methods: An interdisciplinary programme for falls prevention was designed in community-dwelling older adults at falls risk, including physical exercise, nutritional education and falls prevention training. Screening measurements took place before and after the intervention for a complete assessment of the participants' physical, mental and social state. The implementation of the programme coincided with the lockdown due to the COVID-19 pandemic and this led us to a forceful transformation to a pilot digital programme. Thus, the new version of the programme had driven us to minimize face-to face contact and at the same time ensure that the participants' healthcare and social support needs were addressed. Moreover, new engagement techniques had to be used. Therefore, a digital platform was created and hosted by the FFN Greece website and 6 zoom teleconferences were organized with health professionals (orthopaedic, social worker, geriatrician, nutritionist). In addition, the participants could communicate with a psychologist and had zoom dancing lessons once a week. The digital educational material was adapted in order to provide the participants with health information regarding copying with falls incidents during the pandemic home restriction. Results: 20 people participated in the programme (95% women, mean age: 69 years). Among the most important results of the intervention were: The reduction of Fear of Falls (FES-I mean score before and after the intervention 28.1 vs 26.3, respectively);The improvement of important aspects of quality of life (SF-36 Physical Functioning mean score and SF-36 Emotional Well-being mean score before and after the intervention 81.8 vs 88.2 and 75.0 vs 90.2, respectively);The improvement of nutritional habits (Mediterranean Diet Scale mean score before and after the intervention 32.2 vs 34.2, respectively). Conclusion: This pilot programme indicates that health professionals need to be vigilant in adapting falls prevention programmes effectively, even in unpredicted situations like the recent COVID-19 pandemic. The results were encouraging, since there were no falls incidents, the physical, the emotional well-being of the participants and their falls related knowledge and skills were improved.

4.
Geriatric Orthopaedic Surgery and Rehabilitation ; 12:72-73, 2021.
Article in English | EMBASE | ID: covidwho-1817115

ABSTRACT

Introduction: Each year over 3,700 patients over the age of sixty were hospitalised with a hip fracture in Ireland. The recognition of the growing burden of fragility fractures on the health service needs to be factored into the future development of hospital services. The IHFD is a clinically led, web based audit of hip fracture casemix, care and outcomes. The National Office of Clinical Audit (NOCA) provides operational support and governance for the IHFD. All 16 eligible hospitals in the Republic of Ireland are now entering data. It is clinically supported by the Irish Gerontological Society (IGS) and the Irish Institute of Trauma and Orthopaedics (IITOS). The IHFD has been recording data since 2012 and has captured over 25,000 cases to date. Methods: Data is collected through the Hospital In-Patient Enquiry (HIPE) portal in collaboration with the Healthcare Pricing Office (HPO). The IHFD audit was based originally on the six standards of care as published by the British Orthopaedic Association and British Geriatric Society in the "Blue Book", the Care of Patients With Fragility Fracture (2007), but in 2017 the IHFD published the Irish Hip Fracture Standards (IHFS), in 2018 these standards formed the basis of a Best Practice Tariff (BPT), that is, a payment of €1000 per case that meets the IHFS. In 2021 a new standard for early mobilization will become part of the BPT. Results: 33% of patients were admitted to an orthopaedic ward or went to theatre within four hours, 75% of patients received surgery within 48 hours, 3% of patients developed a pressure ulcer, 56% of patients received a nutritional risk assessment to identify risk of malnutrition, 82% of patients were seen by a geriatrician, IHFS 5: 91% of patients received a bone health assessment, 85% of patients received a specialist falls assessment, 78% of patients were mobilised by a physiotherapist on the day of or day after surgery, 28% of patients were discharged directly home. Median of length of stay: 11 days. Conclusion: The coverage has improved consistently year on year and 99% was achieved in 2020. There has been an improvement in all IHFS with a minor disimprovement in 2020 due to COVID. The focus of the audit going forward will be support the hospitals to recover from the impact of the COVID pandemic, to increase the number of patient care meeting the BPT, to support the hospitals to adopt a culture of quality improvement using the IHFD data and to develop a longer term outcome dataset.

5.
Age and Ageing ; 51(SUPPL 1):i4, 2022.
Article in English | EMBASE | ID: covidwho-1815974

ABSTRACT

Introduction: The National Hip Fracture Database indicated Guy's and St Thomas' Trust ranked in the fourth quartile nationally with reference to hospital length of stay (LOS), ∗Note 1 and 2 co lead authors return to original residence (ROR), and mortality in hip fracture patients in 2018. This quality improvement project aimed to improve and maintain these key factors via a twostage process. Methods: Stage one involved implementation of four key interventions through a transdisciplinary focus group, comprising ortho-geriatricians, orthopaedic surgeons, physiotherapists (PT), occupational therapists (OT), nursing staff, and a transfer of care navigator (TCN). Firstly, the New Mobility Score (NMS) was employed as a tool to guide estimated length of stay. Secondly, use of preoperative OT assessment allowed early evaluation of patient expectations concerning discharge planning. Third, facilitation of the discharge process was optimised by the recruitment of a TCN. Lastly, attendance of a senior orthogeriatrician during the daily board round was established. Stage two involved education of new members of the trans-disciplinary team to ensure that the key interventions listed above were maintained on hip fracture patients. Results: Following stage one, average acute hospital LOS and overall LOS decreased from 20.1 to 15.1 days and 22.4 to 18.3 days, respectively. Rate of ROR within 120 days of discharge improved from 72.4% to 86.9%, while mortality rates fell from 7.1 to 3.4. Following stage two, overall LOS improved to 17.1 days, while acute LOS and mortality were maintained at 15.6 and 3.9 days, respectively. While ROR fell to 82.8%, this remained higher than the national average at 69.9%. Conclusions: Utilisation of NMS and multi-disciplinary input effectively improved ROR, while reducing length of hospital stay and mortality rates in hip fracture patients. Education of new members of the trans-disciplinary team allowed sustained improvement despite challenges faced during the COVID-19 pandemic.

6.
Age and Ageing ; 51(SUPPL 1):i16, 2022.
Article in English | EMBASE | ID: covidwho-1815971

ABSTRACT

Background: Advance care planning (ACP) is an ongoing conversation where healthcare professionals explore patients' and families' wishes in order to act within their best interests. The COVID19 pandemic continues to highlight the importance of timely ACP, namely while our patients have capacity. We noted that despite advancing age, accumulating co-morbidities and high clinical frailty scores (CFS);ACP discussions were not taking place within our elderly department. We aimed to increase ACP conversations and ensure documentation on ReSPECT forms to allow continuity within primary care. Methods: 10 patients per ward were randomly selected. 69 patients met inclusion criteria (over 65 with CFS ≥5 or any patient with dementia). We reviewed electronic and paper records and defined evidence of ACP as ReSPECT form including preferred place of death (PPoD), or discussion with patient or relative in medical notes. We randomly selected a pilot ward and applied interventions over 4 weeks: • Small group teaching to junior doctors • Visiting ward MDTs to identify appropriate patients for ACP • Presenting baseline data to geriatricians • Visual aids from the palliative care team and prompt sheets for doctors. Results: Prior to our interventions, 22% of our sample had evidence of advance care planning, 33% of discussions documented on ReSPECT form. Following our intervention period we reviewed medical notes on our pilot ward. 58% patients now had evidence of ACP, with 66% documented on a ReSPECT form. Conclusion: We achieved a significant increase in advance care planning within our elderly medicine department, and are therefore better equipped to provide personalised care alongside our patients' wishes and values. Next steps: • Expanding teaching across the multi-disciplinary team • ACP 'champions' to highlight appropriate patients • Expansion of initial interventions across the departmentWe hope to embed and maintain this change through education, training and inspiring others.

7.
Age and Ageing ; 51(SUPPL 1):i10, 2022.
Article in English | EMBASE | ID: covidwho-1815968

ABSTRACT

Introduction: Evaluation of Wythenshawe Hospital's Acute Frailty Service in January- June 2019 demonstrated slow referrals times and poor identification of frail patients due to inaccurate Clinical Frailty Scoring (CFS) at emergency department triage. This project presents the Results: of ongoing quality assessment of our service between June 2019- January 2021, following two quality improvement (QI) interventions. Aims: To evaluate our service's ability to deliver early identification and intervention for complex frail patients via Complex Geriatric Assessment (CGA), as set out in National and Regional Frailty standards.(1,2). -To improve and maintain better outcomes for patients accessing our frailty service. Method: Intervention1 (July'19): Specialist frailty nurses relocated to ED. Dedicated frailty clinical fellows and Consultant geriatrician input 0900-1700 weekdays. Intervention2 (Sep'20): Short-stay frailty unit opened. Junior clinical fellow cover increased (0900-1900 weekdays and 0900-1700 weekends). 299 patients seen at intervals between Jun'19-Jan'21 analysed using electronic records and completed CGA proformas. Results: Pre-intervention Intervention1 Intervention2 June'19(n = 22) July'19(n = 198) Nov'19(n = 25) Sep'20(n = 26) Jan'21(n = 28) Time from triage-to-CGA (mins) (CI 95%)∗ 372.0±178.2 56.0 83.4±31.0 72.9±35.7 48.4±20.0 Discharge(%): Same day 22.7 39.4 21.7 36.0 25.0<72 hr(cumulative) 72.7 63.6 47.8 68.0 57.1 Ave. length of stay(days)(CI95%) 10.4±5.9 20.6 20.0±8.7 7.1±3.4 5.4±2.1 Readmission <30 days(%) 30.0 9.0 17.4 12.5 25.0 CGA Quality(%) CFS completion 100 96.0100 89.3 ReSPECT discussion 29.3 64.0 61.5 67.9 Full medication review 46.5 96.0 80.8 89.3 Therapy assessment 85.5 92.0 92.3 89.3 ∗patients triaged between 0800-1700. Conclusion: Since Intervention1,Wythenshawe frailty service has sustained a reduction in triage-to-CGA time, maintained high percentages of same-day and<72 hr discharges, and sustained high rates of CFS completion and therapy assessments. Following intervention2, average length of stay reduced. Increased readmission rates in Jan'21 were impacted by COVID-19. Additional interventions targeted at reducing readmission rates and increasing ReSPECT discussions should be implemented. 1. GreaterManchester Frailty Collaborative and Network, 2019. 2. Same-day acute frailty service, NHS improvement, 2019.

8.
Irish Medical Journal ; 114(9), 2021.
Article in English | EMBASE | ID: covidwho-1733402
9.
Blood ; 138:2997, 2021.
Article in English | EMBASE | ID: covidwho-1582280

ABSTRACT

Introduction: Time and resource barriers limit widespread implementation of frailty assessment in oncology practice, and the COVID-19 pandemic has reduced the number of in-person visits. To overcome these barriers, virtual geriatric assessments (GAs) have been developed, but lack important objective performance measures such as gait speed and cognitive tests-measures that are important predictors for poor outcomes in older patients with blood cancers (Liu et al., Blood, 2019;Hshieh et al., JAMA Oncol., 2018). We adapted an in-person frailty assessment to a virtual format that maintained both patient-reported and objective measures. Methods: Our cohort assessed in-person (February 2015 to March 2020;resumed June 2021 to July 2021) included all transplant-ineligible patients aged 75 years and older who presented to DFCI for initial consultation for their hematologic malignancy. On the same day as their initial consult, a research assistant administered to consented patients a screening geriatric assessment that assessed for 42 aging-related health deficits using patient-reported and objective performance measures spanning the domains of function, cognition, comorbidity, and mobility. From this assessment, frailty was measured using both the phenotypic (Fried et al., J Gerontol A Biol Sci Med Sci, 2001) and deficit-accumulation approaches (Rockwood et al., J Gerontol A Biol Sci Med Sci, 2007). The frailty phenotype uses five criteria to define a syndrome (slow gait speed, weakness [grip strength], self-reported exhaustion, low physical activity, and weight loss). The deficit-accumulation method calculates the proportion of deficits present in an individual out of the total number of possible deficits measured. To virtually adapt our assessment (Figure 1), patient-reported items were readily converted to questions administered over video- or teleconference. Of the objective measures, grip strength was replaced with self-reported grip strength. The Clock-in-the-Box test was changed to a simple clock draw that the patient completes and displays to the video camera for scoring. 4-meter gait speed is collected by teaching a caregiver to administer with a stopwatch and a 4-meter strip of ribbon. If video is unavailable, self-reported gait speed is measured instead. We expanded eligibility of virtual assessments to patients aged 70 and older. Geriatricians (C.D., T.H., and J.D.) and oncologists (G.A. and J.D.) reviewed the virtual GA for content validity. We measured the proportion of patients who consented and completed the virtual assessment. We assessed for differences in the distributions of age and frailty between virtual and in-person frailty assessments in patients 75 and older using Fisher exact (age) and Chi-square (frailty) tests. Results: Since starting our virtual frailty assessments in November 2020 through July 2021, 118 patients were enrolled and 89 (75%) completed assessments. Median age was 77.6 years (SD = 4.21), 55 (62%) were male, 38 (43%) had lymphoma, 32 (36%) had leukemia/myelodysplastic syndrome/myeloproliferative disorders, and 19 (21%) had multiple myeloma. Of the 89 who completed virtual assessments, 67 (75%) completed the assessment over video with the remaining 22 (25%) over telephone. For the objective measures, 68 (76%) participants were able to complete the clock draw and 47 (53%) were able to complete the gait speed tests. The distribution of age (p = 0.78) and frailty categories (p = 0.49) in our virtual assessments was similar to that of our in-person assessments (Table 1). Conclusion: We developed and successfully delivered a virtual frailty assessment for older adults with blood cancers and found no evidence that frail patients or patients of the highest age categories were unable to complete them. These data suggest that virtual frailty assessment will allow decentralization of assessments even beyond the pandemic, potentially reaching more older adults with blood cancers. The ability to scale to more patients and measure frailty where it matters most-in their own homes-could help over ome barriers to frailty assessments in busy oncology clinics. Virtual frailty assessments also allow for serial measurement while on treatment to better understand and track the trajectory of frailty in this population. [Formula presented] Disclosures: Kim: Alosa Health: Other: Personal Fee;NIH: Other: Grants;Alosa Health: Other: Personal Fee.

10.
European Heart Journal ; 42(SUPPL 1):971, 2021.
Article in English | EMBASE | ID: covidwho-1554080

ABSTRACT

Heart Failure is frequently associated with several comorbidities such as ischaemic heard disease, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease and frailty. This level of complexity is best dealt with by a multispecialty multidisciplinary team (MDT) model. This was a single centre observational study (January 2020-December 2020) that was undertaken in a British university hospital looking at effect of HF multispecialty virtual MDT meetings on HF outcomes. Patients acted as their own controls outcomes compared for equal period pre versus post MDT meeting. The multi-specialty meeting was conducted once monthly via video-conferencing. It consisted of heart failure cardiologists (from primary secondary and tertiary care), heart failure specialist nurses (hospital and community), nephrologist, endocrinologist, palliative care specialists, chest physician, pharmacist, pharmacologist and geriatrician. Recommendations were made as consensus from the multispecialty meeting. The main outcome measures were 1) number of hospitalisations and 2) outpatient clinic attendances 3) cost savings. A total of 189 patients were discussed from January-December 2020. This was uninterrupted during the COVID-19 pandemic. The mean age was 70.3±18.1 years and median follow-up 6 months (range 1-13 months). The mean Charlson Co-morbidity score was 5.3±1.2 and Rockwood Frailty Score was 4.9±1. The mean number of outpatient clinic attendances avoided was 1.7±0.4. This reduced inconvenience to patients, saved patients money (transport and parking costs) and led to carbon footprint reduction. The MDT meeting total costs were £15,400 and the 31 clinic appointments they generated cost an estimated £3720. However, the MDT meetings prevented 277 clinic appointments (cost saving £33,352). Finally, the mean number of hospitalisations pre-MDT was 0.7 Vs 0.2 post MDT (p<0.01) with a saving of around 730 bed days (estimated cost-saving £260,000). The HF multispecialty virtual MDT approach provides seamless integration of primary care community services with secondary and tertiary care. Consensus decision from MDT meetings provides holistic approach for HF patients with comorbidities and frailty, and reduces inconvenience to patients by preventing the need to attend multiple specialty clinics. This approach can also lead to significant cost-savings to the healthcare system.

11.
J Am Med Dir Assoc ; 23(4): 589-595.e6, 2022 04.
Article in English | MEDLINE | ID: covidwho-1487806

ABSTRACT

OBJECTIVE: This study evaluates the impact of a novel model of care called Geriatric Comanagement of Older Vascular surgery inpatients on clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS: A pre-post study of geriatric comanagement, comparing prospectively recruited preintervention (February-October 2019) and prospectively recruited postintervention (January-December 2020) cohorts. Consecutively admitted vascular surgery patients age ≥65 years at a tertiary academic hospital in Concord and with an expected length of stay (LOS) greater than 2 days were recruited. INTERVENTION: A comanagement model where a geriatrician was embedded within the vascular surgery team and delivered proactive comprehensive geriatric assessment based interventions. METHODS: Primary outcomes of incidence of hospital-acquired geriatric syndromes, delirium, and LOS were compared between groups using univariable and multivariable logistic regression analyses. Prespecified subgroup analysis was performed by frailty status. RESULTS: There were 150 patients in the preintervention group and 152 patients in the postintervention group. The postintervention group were more frail [66 (43.4%) vs 45 (30.0%)], urgently admitted [72 (47.4%) vs 56 (37.3%)], and nonoperatively managed [52 (34.2%) vs 33 (22.0%)]. These differences were attributed to the coronavirus disease 2019 pandemic during the postintervention phase. The postintervention group had fewer hospital-acquired geriatric syndromes [74 (48.7%) vs 97 (64.7%); P = .005] and reduced incident delirium [5 (3.3%) vs 15 (10.0%); P = .02], in unadjusted and adjusted analyses. Cardiac [8 (5.3%) vs 30 (20.0%); P < .001] and infective complications [4 (2.6%) vs 12 (8.0%); P = .04] were also fewer. LOS was unchanged. Frail patients in the postintervention group experienced significantly fewer geriatric syndromes including delirium. CONCLUSIONS AND IMPLICATIONS: This is the first prospective study of inpatient geriatric comanagement for older vascular surgery patients. Reductions in hospital-acquired geriatric syndromes including delirium, and cardiac and infective complications were observed after implementing geriatric comanagement. These benefits were also demonstrated in the frail subgroup.


Subject(s)
COVID-19 , Inpatients , Aged , Geriatric Assessment , Humans , Length of Stay , Prospective Studies , Syndrome , Tertiary Care Centers , Vascular Surgical Procedures
12.
Ageing Res Rev ; 69: 101373, 2021 Aug.
Article in English | MEDLINE | ID: covidwho-1242880

ABSTRACT

The coronavirus disease 19 (COVID-19) is relevant in older people. Attention was given to the nursing homes in which frailer people are usually admitted. In this review, we discuss the approaches for daily problems found in nursing home as geriatricians and potentially new research directions. We start with the problem of the older people affected by dementia and Behavioral and Psychological Symptoms of Dementia for which also the execution of a simple diagnostic test (such as nasopharyngeal swab) could be problematic. Another important problem is the management of wandering patients for which the re-organization of the spaces and vaccination could be the solutions. The relationship with families is another important problem, also from a medico-legal point of view, that can be faced using video conferencing tools. Moreover, we discussed the importance of stratifying prognosis in older nursing home residents for the best management and therapeutically approach, including palliative care, also using telemedicine and the inclusion of prognostic tools in daily clinical practice. Finally, we approached the therapeutical issues in older people that suggests the necessity of future research for finding older-friendly medications.


Subject(s)
COVID-19 , Dementia , Aged , Dementia/therapy , Geriatricians , Humans , Nursing Homes , SARS-CoV-2
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