An orthogeriatric service can reduce prolonged hospital length of stay in hospital for older adults admitted with hip fractures: a monocentric study.

BACKGROUND: The Blue Book (2005), recommended guidelines for patients care with fragility fractures. Together with introduction of a National Hip Fracture Database Audit and Best Practice Tariff model to financially incentivise hospitals by payment of a supplement for patients whose care satisfied six clinical standards), have improved hip fracture after-care. However, there is a lack of data-driven evidence to support its effectiveness. We aimed to verify the impact of an orthogeriatric service on hospital length of stay (LOS)-duration from admission to discharge. METHODS: We conducted a repeated cross-sectional study over a 10 year period of older individuals aged ≥ 60 years admitted with hip fractures to a hospital. RESULTS: Altogether 2798 patients, 741 men and 2057 women (respective mean ages; 80.5 ± 10.6 and 83.2 ± 8.9 years) were admitted from their own homes with a hip fracture and survived to discharge. Compared to 2009-2014, LOS during 2015-2019, when the orthogeriatric service was fully implemented, was shorter for all discharge destinations: 10.4 vs 17.5 days (P < 0.001). Each discharge destination showed reductions: back to own homes, 9.7 vs 17.7 days (P < 0.001); to rehabilitation units: 10.8 vs 13.1 days (P < 0.001); to residential care: 15.4 vs 26.2 days (P = 0.001); or nursing care, 24.4 vs 53.1 days (P < 0.001). During 2009-2014, the risk of staying > 3 weeks in hospital was greater by six-fold and pressure ulcers by three-fold. The number of bed days for every thousand patients per year was also shortened during 2015-2019 by: 1665 days for discharge back to own homes; 469 days with transfer to rehabilitation units; 1258 days for discharge to residential care, and 5465 days to nursing care. Estimated annual savings (2017 costs) per thousand patients after complete establishment of the service was about £2.7 m. CONCLUSIONS: Implementation of an orthogeriatric service generated significant reductions in hospital LOS for all patients, with associated cost-savings, especially for those discharged to nursing care.

Sex differences in clinical outcomes amongst 1105 patients admitted with hip fractures.

Amongst hip fracture admissions, mortality is higher in men than in women. However, sex differences in other care-quality measures have not been well-documented. We aimed to examine sex differences in mortality as well as a wide range of underlying health indicators and clinical outcomes in adults ≥ 60 year of age admitted with hip fractures from their own homes to a single NHS hospital between April-2009 and June-2019. Sex differences in delirium, length of stay (LOS) and mortality in hospital, readmission, and discharge destination, were examined by logistic regression. There were 787 women and 318 men of similar mean age (± SD): 83.1 year (± 8.6) and 82.5 year (± 9.0), respectively (P = 0.269). There were no sex differences in history of dementia or diabetes, anticholinergic burden, pre-fracture physical function, American Society of Anesthesiologists grades, or surgical and medical management. Stroke and ischaemic heart disease, polypharmacy, and alcohol consumption were more common in men. After adjustment for these differences and age, men had greater risk of delirium (with or without cognitive impairment) within one day of surgery: OR = 1.75 (95%CI 1.14-2.68), LOS ≥ 3 weeks in hospital: OR = 1.52 (1.07-2.16), mortality in hospital: OR = 2.04 (1.14-3.64), and readmission once or more after 30 days of a discharge: OR = 1.53 (1.03-2.31). Men had a lower risk of a new discharge to residential/nursing care: OR = 0.46 (0.23-0.93). The present study revealed that, in addition to a greater risk of mortality than women, men also had many other adverse health outcomes. These findings, which have not been well-documented, serve to stimulate future targeted preventive strategies and research.

Association of Polypharmacy and Anticholinergic Burden with Length of Stay in Hospital Amongst Older Adults Admitted with Hip Fractures: A Retrospective Observational Study.

BACKGROUND: Age-associated multimorbidity and polypharmacy, predispose individuals to falls and consequent hip fractures. We examined the impact of polypharmacy (≥ 4 drugs daily), including anticholinergic agents, on hospital length of stay (LOS), mobility within 1-day of hip surgery and pressure ulcers in adults ≥ 60 years admitted with hip fractures. METHODS: In this retrospective observational study, information on medications at admission was obtained to calculate the total number of drugs taken, including those imposing an anticholinergic burden (ACB). Associations between variables were examined by logistic regression; adjusted for age, sex, co-morbidities, pre-fracture functional limitations and alcohol consumption. RESULTS: There were 787 women and 318 men of similar mean age (± SD): 83.1 years (± 8.6) and 82.5 years (± 9.0), respectively. Compared to patients with an ACB score = 0 and taking < 4 drugs daily, those with an ACB score ≥ 1 and taking ≥ 4 drugs daily had greater risk of prolonged LOS (≥ 2 weeks), OR 1.8 (1.2-2.7); failure to mobilise within 1-day of surgery, OR 1.9 (1.1-3.3); and pressure ulcers, OR 3.0 (95% CI 1.2-7.9). LOS was further prolonged by failure to mobilise within 1-day of surgery and/or pressure ulcers. Those with either an ACB score ≥ 1 or the use of ≥ 4 drugs daily had intermediate risks. CONCLUSIONS: Anticholinergic agents and polypharmacy in patients with hip fractures are associated with longer LOS in hospital, further accentuated by failure to mobilise within 1-day after surgery and pressure ulcers. This study provides further evidence of the impact of polypharmacy, including those with an ACB, on adverse health outcomes and lends support to reduce potentially inappropriate prescribing.

Identification of preoperative factors and postoperative outcomes in relation to delays in surgery for hip fractures.

We evaluated factors and outcomes associated with elapsed time to surgery (ETTS) in 1,081 men and 2,891 women (mean age 83.5 years ±9.1) undergoing hip fracture surgery (from 2009-2019). Mortality rates were 4.8%, 6.3%, 6.2% and 10.3% (chi-squared 19.0; p<0.001), and hospital length of stay (LOS) >19 days were 31.9%, 32.8%, 33.8% and 43.2% (chi-squared 18.5; p<0.001) for ETTS <24 hours, 24-35 hours, 36-47 hours and ≥48 hours, respectively. There were no differences between ETTS categories for failure to mobilise within 1 day of surgery, pressure ulcers or discharge to nursing care. After adjustment for age, sex, American Society of Anesthesiologists' score and years of data collection, compared with Sunday, the risk of ETTS ≥36 hours was highest on Friday (odds ratio (OR) 3.50; 95% confidence interval (CI) 2.43-5.03) and Saturday (OR 4.70; 95% CI 3.26-6.76). Compared with ETTS <24 hours, there were increases in the risk of death when ETTS ≥48 hours (OR 2.31; 95% CI 1.47-3.65) and LOS >19 days (OR 1.34; 95% CI 1.02-1.75). The median (interquartile range (IQR)) LOS for ETTS <24 hours was 12.7 days (IQR 8.0-23.0), 24-35 hours was 13.5 days (IQR 8.4-22.9), 36-47 hours was 14.1 days (IQR 8.9-23.3) and ≥48 hours was 16.9 (IQR 10.8-27.0; p<0.001). The 10-year period of collection did not change the conclusion. Admissions towards the end of the week are associated with delayed ETTS for hip fractures, while delay in surgery, particularly beyond 48 hours, is associated with increased risk of mortality and prolonged LOS.

Changes in Characteristics and Outcomes of Patients Undergoing Surgery for Hip Fractures Following the Initiation of Orthogeriatric Service: Temporal Trend Analysis.

The Blue Book published by the British Orthopaedic Association and British Geriatrics Society, together with the introduction of National Hip Fracture Database Audit and Best Practice Tariff, have been influential in improving hip fracture care. We examined ten-year (2009-2019) changes in hip fracture outcomes after establishing an orthogeriatric service based on these initiatives, in 1081 men and 2891 women (mean age = 83.5 ± 9.1 years). Temporal trends in the annual percentage change (APC) of outcomes were identified using the Joinpoint Regression Program v4.7.0.0. The proportions of patients operated beyond 36 h of admission fell sharply during the first two years: APC = - 53.7% (95% CI - 68.3, - 5.2, P = 0.003), followed by a small rise thereafter: APC = 5.8% (95% CI 0.5, 11.3, P = 0.036). Hip surgery increased progressively in patients > 90 years old: APC = 3.3 (95% CI 1.0, 5.8, P = 0.011) and those with American Society of Anaesthesiologists grade ≥ 3: APC = 12.4 (95% CI 8.8, 16.1, P < 0.001). There was a significant decline in pressure ulcers amongst patients < 90 years old: APC = - 17.9 (95% CI - 32.7, 0.0, P = 0.050) and also a significant decline in mortality amongst those > 90 years old: APC = - 7.1 (95% CI - 12.6, - 1.3, P = 0.024). Prolonged length of stay (> 23 days) declined from 2013: APC = - 24.6% (95% CI - 31.2, - 17.4, P < 0.001). New discharge to nursing care declined moderately over 2009-2016 (APC = - 10.6, 95% CI - 17.2, - 2.7, P = 0.017) and sharply thereafter (APC = - 47.5%, 95%CI - 71.7, - 2.7, P = 0.043). The rate of patients returning home was decreasing (APC = - 2.9, 95% CI - 5.1, - 0.7, P = 0.016), whilst new discharge to rehabilitation was increasing (APC = 8.4, 95% CI 4.0, 13.0; P = 0.002). In conclusion, the establishment of an orthogeriatric service was associated with a reduction of elapsed time to hip surgery, a progressive increase in surgery carried out on high-risk adults and a decline in adverse outcomes.

Increased Association With Malnutrition and Malnourishment in Older Adults Admitted With Hip Fractures Who Have Cognitive Impairment and Delirium, as Assessed by 4AT.

BACKGROUND: The Royal College of Physicians recently introduced the 4AT (Alertness, Abbreviated Mental Test-4, Attention, and Acute change or fluctuating course) for screening cognitive impairment and delirium. Here, we examined the association of the 4AT with nutrition status in patients admitted to a hospital with hip fractures between January 1, 2016, and June 6, 2019. METHODS: Nutrition status was assessed using the Malnutrition Universal Screening Tool, and the 4AT was assessed within 1 day after hip surgery. χ2 Tests and logistic regression were conducted to assess the association of nutrition status with 4AT scores, adjusted for age and sex. RESULTS: From 1082 patients aged 60-103 years, categorized into 4AT scores of 0, 1-3, or ≥4, the prevalence of malnutrition risk was 15.5%, 27.3%, and 39.6% and malnourishment was 4.1%, 13.2%, and 11.3%, respectively. Compared with the 4AT = 0 cohort, a 4AT score = 1-3 was associated with an increased malnutrition risk (odds ratio [OR], 2.3; 95% CI, 1.6-3.1) or malnourishment (OR, 3.6; 95% CI, 2.1-6.3). For a 4AT score ≥4, corresponding ORs were 4.0 (95% CI, 2.8-5.9) and 3.6 (95% CI, 1.9-6.8). Overall, there was a significant positive association: as 4AT scores increased, so did malnutrition risk. CONCLUSIONS: Among older adults admitted with hip fractures, high 4AT scores, which are suggestive of cognitive impairment and delirium, identified patients at increased malnutrition risk. These findings lend further support for the use of 4AT to identify patients who are at increased health risk.

Clinical outcomes in patients admitted to hospital with cervical spine fractures or with hip fractures.

Patients admitted with a cervical fracture are twice as likely to die within 30 days of injury than those with a hip fracture. However, guidelines for the management of cervical fractures are less available than for hip fractures. We hypothesise that outcomes may differ between these types of fractures. We analysed 1359 patients (406 men, 953 women) with mean age of 83.8 years (standard deviation = 8.7) admitted to a National Health Service hospital in 2013-2019 with a cervical (7.5%) or hip fracture (92.5%) of similar age. The association of cervical fracture (hip fracture as reference), hospital length of stay (LOS), co-morbidities, age and sex with outcomes (acute delirium, new pressure ulcer, and discharge to residential/nursing care) was assessed by stepwise multivariate logistic regression. Acute delirium without history of dementia was increased with cervical fractures: odds ratio (OR) = 2.4, 95% confidence interval (CI) = 1.3-4.7, age ≥ 80 years: OR = 3.5 (95% CI = 1.9-6.4), history of stroke: OR = 1.8 (95% CI = 1.0-3.1) and ischaemic heart disease: OR = 1.9 (95% CI = 1.1-3.6); pressure ulcers was increased with cervical fractures: OR = 10.9 (95% CI = 5.3-22.7), LOS of 2-3 weeks: OR = 3.0 (95% CI = 1.2-7.5) and LOS of ≥ 3 weeks: OR = 4.9, 95% CI = 2.2-11.0; and discharge to residential/nursing care was increased with cervical fractures: OR = 3.2 (95% CI = 1.4-7.0), LOS of ≥ 3 weeks: OR = 4.4 (95% CI = 2.5-7.6), dementia: OR = 2.7 (95% CI = 1.6-4.7), Parkinson's disease: OR = 3.4 (95% CI = 1.3-8.8), and age ≥ 80 years: OR = 2.7 (95% CI = 1.3-5.6). In conclusion, compared with hip fracture, cervical fracture is more likely to associate with acute delirium and pressure ulcers, and for discharge to residency of high level of care, independent of established risk factors.

Prevalence and consequences of malnutrition and malnourishment in older individuals admitted to hospital with a hip fracture.

BACKGROUND/OBJECTIVES: Major causes of hip fractures are osteoporosis and falls, both of which are determined by nutrition. Information on the nutritional status of patients admitted to hospital with a hip fracture is lacking. In this study, we assessed determinants and adverse outcomes associated with malnutrition and malnourishment. METHODS: Nutritional status, assessed using the Malnutrition Universal Screening Tool protocol, was compared to age and residency prior to admission, and outcomes during hospital stay and at discharge. RESULTS: A total of 1239 patients admitted with a hip fracture (349 men, 890 women), aged 60-100 years. Compared with well-nourished individuals, the prevalences of malnutrition risk or malnourishment were higher in older age groups and those from residential or nursing care. Those with risk of malnutrition or malnourishment stayed in hospital longer by 3.0 days (95% confidence interval (CI), 1.5-4.5 days; p < 0.001) and 3.1 days (95% CI, 0.7-5.5 days; p = 0.011), respectively. Compared with the well-nourished group, malnourished individuals had increased: (1) risk for failure to mobilise within 1 day of surgery (rates = 17.9 versus 27.0%; odds ratio (OR) = 1.6 (95% CI, 1.0-2.7), p = 0.045); (2) pressure ulcers (rates = 1.0% versus 5.0%; OR = 5.5 (95% CI, 1.8-17.1), p = 0.006); (3) in-patient mortality (rates = 4.5% versus 10.1%; OR = 2.3 (95% CI, 1.1-4.8) p = 0.033) and (4) discharge to residential/nursing care: rates = 4.3% versus 11.1%; OR = 2.8 (95% CI, 1.2-6.6), p = 0.022. CONCLUSIONS: Inadequate nutrition is common in patients admitted to hospital with a hip fracture, which in turn predisposes them to a number of complications. More research on nutritional support should be directed to this group to prevent or minimise hip fractures.

The Ability of the Nottingham Hip Fracture Score to Predict Mobility, Length of Stay and Mortality in Hospital, and Discharge Destination in Patients Admitted with a Hip Fracture.

The Nottingham Hip Fracture Score (NHFS) has been developed for predicting 30-day and 1-year mortality after hip fracture. We hypothesise that NHFS may also predict other adverse events. Data from 666 patients (190 men, 476 women), aged 60.2-103.4 years, admitted with a hip fracture to a single centre from 1/10/2015 and 7/12/2017 were analysed. The ability of NHFS to predict mobility within 1 day after surgery, length of stay (LOS) find mortality, and discharge destination was evaluated by receiver operating characteristic curves and two-graph plots. The area under the curve (95% confidence interval [CI]) for predicting mortality was 67.4% (58.4-76.4%), prolonged LOS was 59.0% (54.0-64.0%), discharge to residential/nursing care was 62.3% (54.0-71.5%), and any two of failure to mobilise, prolonged LOS or discharge to residential/nursing care was 64.8% (59.0-70.6%). NHFS thresholds at 4 and 7 corresponding to the lower and upper limits of intermediate range where sensitivity and specificity equal 90% were identified for mortality and prolonged LOS, and 4 and 6 for discharge to residential/nursing care, which were used to create three risk categories. Compared with the low risk group (NHFS = 0-4), the high risk group (NHFS = 7-10 or 6-10) had increased risk of in-patient mortality: rates = 2.0% versus 7.1%, OR (95% CI) = 3.8 (1.5-9.9), failure to mobilise within 1 day of surgery: rates = 18.9% versus 28.3%, OR = 1.7 (1.0-2.8), prolonged LOS (> 17 days): rates = 20.3% versus 33.9%, OR = 2.2 (1.3-3.3), discharge to residential/nursing care: rates = 4.5% vs 12.3%, OR = 3.0 (1.4-6.4), and any two of failure to mobilise, prolonged LOS or discharge to residential/nursing care: rates = 10.5% versus 28.6%, 3.4 (95% CI 1.9-6.0), and stayed 4.1 days (1.5-6.7 days) longer in hospital. High NHFS associates with increased risk of mortality, prolonged LOS and discharge to residential/nursing care, lending further support for its use to identify adverse events.

Associations of 4AT with mobility, length of stay and mortality in hospital and discharge destination among patients admitted with hip fractures.

BACKGROUND: the 4AT (Alertness, Abbreviated Mental Test-4, Attention and Acute change or fluctuating course), a tool to screen cognitive impairment and delirium, has recently been recommended by the Scottish Intercollegiate Guidelines Network. We examined its ability to predict health outcomes among patients admitted with hip fractures to a single hospital between January 2018 and June 2019. METHODS: the 4AT was performed within 1 day after hip surgery. A 4AT score of 0 means unlikely delirium or severe cognitive impairment (reference group); a score of 1-3 suggests possible chronic cognitive impairment, without excluding possibility of delirium; a score ≥ 4 suggests delirium with or without chronic cognitive impairment. Logistic regression, adjusted for: age; sex; nutritional status; co-morbidities; polypharmacy; and anticholinergic burden, used the 4AT to predict mobility, length of stay (LOS), mortality and discharge destination, compared with the reference group. RESULTS: from 537 (392 women, 145 men: mean = 83.7 ± standard deviation [SD] = 8.8 years) consecutive patients, 522 completed the 4AT; 132 (25%) had prolonged LOS (>2 weeks) and 36 (6.8%) died in hospital. Risk of failure to mobilise within 1 day of surgery was increased with a 4AT score ≥ 4 (OR = 2.4, 95% confidence interval [CI] = 1.3-4.3). Prolonged LOS was increased with 4AT scores of 1-3 (OR = 2.4, 95%CI = 1.4-4.1) or ≥4 (OR = 3.1, 95%CI = 1.9-6.7). In-patient mortality was increased with a 4AT score ≥ 4 (OR = 3.1, 95%CI = 1.2-8.2) but not with a 4AT score of 1-3. Change of residence on discharge was increased with a 4AT score ≥ 4 (OR = 3.1, 95%CI = 1.4-6.8). These associations persisted after excluding patients with dementia. 4AT score = 1-3 and ≥ 4 associated with increased LOS by 3 and 6 days, respectively. CONCLUSIONS: for older adults with hip fracture, the 4AT independently predicts immobility, prolonged LOS, death in hospital and change in residence on discharge.

Predictive model of length of stay in hospital among older patients.

BACKGROUND: Most National Health Service (NHS) hospital bed occupants are older patients because of their frequent admissions and prolonged length of stay (LOS). We evaluated demographic and clinical factors as predictors of LOS in a single NHS Trust and derived an equation to estimate LOS. METHODS: Stepwise logistic and linear regressions were used to predict prolonged LOS (upper-quintile LOS > 17 days) and LOS respectively, from demographic factors and acute and pre-existing conditions. RESULTS: Of 374 (men:women = 127:247) admitted patients (20% to orthogeriatric, 69% to general medical and 11% to surgical wards), median age of 85 years (IQR = 78-90), 77 had acute first hip fracture; 297 had previous hip fracture (median time since previous fracture = 2.4 years) and 21 (7.1%) had recurrent hip fracture, with median time since first fracture = 2.4 years. Median LOS was 6.5 days (IQR = 1.8-14.8), and 38 (10.2%) died after 4.8 days (IQR = 1.6-14.3). Prolonged LOS was associated with discharge to places other than usual residence: OR = 3.1 (95% CI 1.7-5.7), acute stroke: OR = 10.1 (3.7-26.7), acute first hip fractures: OR = 6.8 (3.1-14.8), recurrent hip fractures: OR = 9.5 (3.2-28.7), urinary tract infection/pneumonia: OR = 4.0 (2.1-8.0), other acute fractures: OR = 9.8 (3.0-32.3) and malignancy: OR = 15.0 (3.1-71.8). Predictive equation showed estimated LOS was 11.6 days for discharge to places other than usual residence, 15 days for pre-existing or acute stroke, 9-14 days for acute and recurrent hip fractures, infections, other acute fractures and malignancy; these factors together explained 32% of variability in LOS. CONCLUSIONS: A useful estimate of outcome and LOS can be made by constructing a predictive equation from information on hospital admission, to provide evidence-based guidance for resource requirements and discharge planning.

Does a daily consultant ward round affect the outcomes of orthopaedic patients?

INTRODUCTION: In the UK, more than 60 000 patients present with a fractured neck of femur each year. These patients represent a huge financial cost. This study looks at the 30-day readmissions and total length of hospital stay of patients presenting with a fractured neck of femur, as well as length of stay in non-hip fracture trauma patients, following the change to a daily consultant-led ward round. METHODS: A total of 200 records of patients with fractured neck of femur were reviewed with data collected retrospectively and prospectively following the introduction of the daily consultant-led ward round. Readmissions were classed as patients who spent a period of time admitted to hospital. Those who only attended an emergency unit were not included. Reasons for readmission and length of readmission were reviewed as were the initial and total length of stay. The authors also evaluated the length of stay in trauma patients (non-hip fracture emergency admissions) for a period of 6 months before and 4 months after the new working model was introduced. RESULTS: With the new working pattern, there was a reduction in the length of stay in those readmitted (13 vs 8 days), and the total length of stay of readmitted patients was also considerably lower (23 vs 13 days). In non-hip fracture trauma patients, there was a reduction in length of stay (8 vs 6 days). CONCLUSIONS: This study demonstrates that by adopting a daily orthopaedic consultant-led ward round, it is possible to reduce the length of stay for patients with a fractured neck of femur, both on initial and subsequent hospital admissions, as well reducing the length of stay for non-hip fracture trauma patients.

Developing, implementing and evaluating an end of life care intervention.

Aim To develop, implement and evaluate a collaborative intervention in care homes seeking to increase the confidence and competence of staff in end of life care and enable more people to receive end of life care in their usual place of residence. Method A two-phase exploratory mixed methods design was used, evaluating the effect of an end of life care toolkit and associated training in care homes, facilitated by a specialist palliative care team. Six care homes in England were recruited to the intervention; 24 staff participated in discussion groups; 54 staff attended at least one training session; and pre- and post-intervention questionnaires were completed by 78 and 103 staff respectively. Results Staff confidence in receiving emotional and clinical support and managing end of life care symptoms increased post-intervention, but confidence in discussing death and dying with residents and relatives decreased. Audit data indicate greater reduction in the number of residents from participating care homes dying in hospital than those from comparison homes. Conclusion Collaborative end of life care interventions support care home staff to manage end of life and may enable residents to have choice about their place of death.

Home is where our journey begins - getting more patients home after a hip fracture with an orthopaedic supportive discharge team.

Hip fracture (neck of femur fracture (NOF)) patients spend a significant amount of time in hospitals, recuperating after the acute event and undergoing rehabilitation. This model of care increases the risk of institutionalisation and may lead to hospital-related harm. An orthopaedic supportive discharge team was set up using a £90,000 grant from the Ashford and St Peter's NHS Foundation Trust's Innovation Fund and care was improved using plan-do-study-act cycles. The team was operational from the 1 March 2014 with the capacity to support eight patients. Engagement meetings were held with patients, GPs and community partners. To reduce risk of readmission, patients were given fast track access to fracture and geriatric clinics. The team's capacity increased to 12 patients through efficiency and introduction of cross-specialty working. The addition of a nurse and therapy assistant - coupled with further improvement in processes - increased capacity still further to 20 patients. In 2 years, 459 patients (211 NOFs) were referred to orthopaedic supportive discharge. Home-to-home discharges improved from 53.9% to 66.3% and length of stay reduced from 21.5 to 14.03 days, enabling a rehabilitation ward to be closed with significant cost savings for NOF patients. 99.6% of patients using orthopaedic supportive discharge provided positive feedback. Orthopaedic supportive discharge should be part of NOF services as it is cost effective, increases home-to-home discharges and reduces length of stay.

Reducing mortality from hip fractures: a systematic quality improvement programme.

Hip fracture is one of the most serious consequences of falls in the elderly, with a mortality of 10% at one month and 30% at one year. Elderly patients with hip fractures have complex medical, surgical, and rehabilitation needs, and a well-coordinated multidisciplinary team approach is essential for the best outcome. The model of best practice for hip fracture care is set out in the Orthopaedic Blue Book and is incentivised by the best practice tariff. In 2009 to 2010, only 39.6% of our patients were being operated on within 36 hours, 19% achieved best practice tariff [1], and mortality was 7.8%. We were ranked as one of the worst hospitals to achieve best practice tariff [1] and our mortality was average. The orthogeriatrics team at Ashford & St Peter's NHS Trust (SPH) was implemented in 2010. Through a system redesign, regular governance meetings, audits and quality improvement projects, we have managed to improve care for our patients and reduce mortality. Over the last three years we have successfully achieved best care for our hip fracture patients, demonstrating a steady improvement in our attainment of the best practice tariff and a reduction in mortality to 5.3% in 2013, which ranks us amongst the best trusts nationally.

Geriatrician input into nursing homes reduces emergency hospital admissions.

Nursing home residents are often very dependent, very frail and have complex care needs. Effective partnerships between primary and secondary care will be of benefit to these residents. We looked at 1954 admission episodes to our Trust from April 2006 to March 2009 inclusive. 3 nursing homes had the highest number of multiple admissions (≥ 4). Four strategies to reduce hospital admissions were used at these nursing homes for 3 months. An alert was also sent to the geriatrician if one of the residents was admitted so that their discharge from hospital could be expedited. The project was then extended for another 4 months with 6 nursing homes. The results showed that geriatrician input into nursing homes had a significant impact on admissions from nursing homes (χ(2)(2)=6.261, p < 0.05). The second part of the project also showed significant impact on admissions (χ(2)(2) = 12.552, p < 0.05). Furthermore, in both parts of the project the length of stay in hospital for the residents was reduced. Geriatricians working together with co-ordinated multidisciplinary teams are well placed to manage the care needs of frail, elderly care home residents.

Training in elder abuse: the experience of higher specialist trainees in Geriatric Medicine in the UK.

Little is known about elder abuse training in post-graduate medical education in the United Kingdom. A questionnaire survey was conducted among Specialist Registrars (SpRs) in Geriatric Medicine attending a single training day within five UK Post-graduate Deaneries to assess self-report experience of elder abuse training during their post-graduate medical education. The questionnaire included quantity, quality and self-report confidence in dealing with elder abuse issues. A total of 112 questionnaires were returned (response rate 100%, representing 78.9% of eligible trainees within these five deaneries). The majority of the participants rated low scores for both quantity and quality of training they received. This finding was consistent across all 5 years of training with no significant difference in rating scores in more experienced (years 3-5) SpRs. The majority (62.5%) of final year SpRs reported feeling inadequately prepared to deal with cases of elder abuse. The results of our survey suggest that the provision and quality of training regarding elder abuse is poor for trainees in Geriatric Medicine. The majority of SpRs approaching the completion of their training felt ill-prepared in managing such cases. Our study highlights the requirement of structured approach in elder abuse training for trainees in Geriatric Medicine.