Bone Health

Introduction: Patients with learning disabilities (LD) often have complex medical needs resulting in onset of frailty at younger ages. This increases risk of morbidity and mortality following emergency admissions, such as acute fractured neck of femur (FNOF). This risk is further increased by communication difficulties experienced in this group. There is little information about how LD affects the quality of care of patients with FNOF as defined by the national hip fracture standards (NHFS).

Methods: This retrospective audit reviewed notes of patients with LD admitted to a teaching hospital with FNOF over 5 years. The audit examined whether the care of patients with LD complied with the NHFS and best practice tariff guidelines, regardless of age. The audit sought to explore potential disparities between patients with LD and the general population. It assessed whether steps were taken to optimise care as defined by the Royal College of Physicians toolkit for LD.

Results: 46 patients were included; 22% were under the age of 60. Operative management was in line with recommendations. However 37% did not receive appropriate bone strengthening treatment and 37% were not mobilised within the first 24 hours. This correlated with fewer patients remaining freely mobile following the admission (8.7% post-operatively vs 41.3% pre-operatively). Documentation of LD severity LD and usual behaviours was unreliable, as was documentation of key conversations, such as those regarding capacity or resuscitation.

Conclusions: This highlights the importance of addressing the increased needs of patients with LD regardless of age, to better facilitate holistic assessment and treatment of this vulnerable population. Locally we plan to minimise variation by utilizing LD nurses and providing comprehensive geriatric review of all patients with LD admitted with FNOF. We recommend that data collection, including 120-day follow-up, be incorporated into routine practice for all patients with LD admitted with FNOF.

Introduction:

Many elderly patients admitted to hospital have presented following a fall. Causes for falls are often complex and multifactorial, but causes such as postural hypotension and cardiac arrhythmias are easily diagnosed with lying and standing blood pressure (LSBP) and ECG respectively. Therefore these investigations should be offered as a minimum to any elderly patient after a fall. We aim to review and improve the number of patients receiving LSBP and ECG after presenting to the Acute Frailty Unit (AFU) with a fall.

Methods:

Falls admissions were reviewed over two four-week periods, before and after intervention. We gathered information on whether patients had LSBP and ECG, and whether these were reviewed and documented by a doctor or specialist nurse. Patients who could not stand for LSBP were not included. Interventions included teaching for all staff on AFU about LSBP and ECGs, posters about investigations after falls, flash cards on how and when to perform LSBPs and a daily tick-box to complete at handover confirming investigations had been reviewed.

Results:

During the first four weeks, 31 patients were identified who presented with falls. 31 (100%) had LSBP recorded and 25 (81%) of these had documentation that it had been reviewed by doctor or specialist nurse. 26 (84%) received an ECG and 24 (94%) of these had a documented review. After intervention, 42 patients were identified. 40 (95%) had LSBP recorded, 40 (100%) of these were reviewed. 42 (100%) of patients had an ECG and 42 (100%) of these were reviewed.

Conclusion:

Multiple simple interventions including education, visual prompts and procedural changes can improve practice and help to ensure that minimum investigations are achieved for all frail patients presenting with falls. These interventions could be applied to other common presentations on the AFU and may be an appropriate next step.

Objective

To conduct a QIP to ensure that >80% of DAU patients’ vision was assessed via the VAT as per National Audit of Falls Prevention Guidance.

Background

Patients with visual impairment are twice as likely to fall than those without. The NAIF 2015 report identified <50% of elderly patients had their vision assessed in hospital; also evident at Southend Hospital.

Methods

Data collection from 56 patients over 8 weeks following weekly interventions helped us analyse their impact on VAT use. Control data (week 1) was pre-intervention.

Intervention

Six interventions were applied over 7 weeks: teaching to nurses, HCAs and doctors about VAT; email to Geriatrics team; reminder email to DAU nursing team and a feedback questionnaire.

Results and Discussion

Mean age was 82 and 38% of patients attending DAU had an ophthalmic history. Pre-intervention (week 1) identified 0% VAT use. In week 2, there was a 75% increase in VAT use after teaching nursing and HCA staff. In week 3, there was only 12.5% VAT use after the poster intervention. In week 4, there was a 25% uptake on VAT use with no intervention.

Week 5’s intervention witnessed 100% in VAT use, which remained high in week 6 (85.7%), 7 (100%) and 8 (100%). The final intervention questionnaire highlighted that 100% of staff were (i) previously unaware of VAT, (ii) agreed on its importance in assessment of elderly patients, (iii) found teaching adequate, (iv) thought there was enough awareness on VAT use via the QIP, (v) agreed that an incomplete VAT was due to inability to undertake section 4 and 5.

Conclusion

VAT use identified 3 ophthalmic problems that would have otherwise not been managed. While the QIP did not meet the target of >80% VAT use, it successfully informed DAU staff in proper conduct of VAT in falls patients.

Introduction:

In 2019, the Royal College of Physicians (RCP) advised that all patients should have their vision screened if identified as a falls risk. Our aim was to implement a bedside visual screening test and establish an onward inpatient referral to Hospital Eye Services (HES).

Method:

This is a collaborative Quality Improvement project involving Geriatric Medicine, HES and the Royal National Institute of Blind People (RNIB). A pilot study cross referenced falls admissions with previous known ophthalmic data to estimate the proportion of known vision loss in this group. In the second phase of the project, a bedside visual screening test has been introduced for all patients admitted to COTE with a fall. Patients failing the screening are reviewed by an RNIB Eye Clinic Liasion Officer (ECLO) and if necessary, a prompt inpatient HES review is arranged.

Results:

Of 182 patients admitted following a fall, in the pilot study, 112 (61%) were known to ophthalmology previously. Of patients known to ophthalmology, 28 (25%) had vision of 6/18 or worse and would be considered to struggle with daily living tasks. 12 (10%) had a certificate of visual impairment (CVI) and 3 (3%) were eligible for CVI but had not been previously registered. One year following implementation of bedside vision testing, 287 patients had been reviewed after failing bedside screening. 97 of these had an onward referral sent or an intervention performed. The first ‘COTE ECLO’ post has been funded as a result of this work.

Conclusion:

Assessing vision is a critical element of the assessment of patients with falls. Through collaboration with the RNIB and Ophthalmology a successful pathway has been developed to address visual impairment in this vulnerable group of patients.

Promoting Bone Health by ensuring in-patient Ortho-geriatrician Bone Health plan in patient notes following Neck of Femur Fracture (NOF).

1. Introduction & Aims

Osteoporosis affects 3 million people in the UK with more than 500,000 hospital presentations annually due to fragility fractures costing in excess of £4.4 billion to the NHS. Bone protective medications are a cost-effective way of reducing fracture and admission following a fall.

The Royal College of Physicians National Hip Fracture Database targets that patients are: “given suitable bone strengthening treatment and followed up to ensure that they are still receiving this protection 120 days after fracture”. Lewisham Hospital achieves this in only 22% of suitable patients against a national average of 35%.

This project aimed to increase the number of eligible NOF patients on bone protective medication.

2. Method

Data was collected for patients over the age of 65 admitted with NOF. 22 eligible patients were admitted from 01/01/23 to 28/02/23 and 16 from 01/03/23 to 31/05/23. It was identified whether an appropriate bone health plan, including FRAX and calcium/vitamin D supplementation, was recorded in the medical notes and electronic departure note (EDN). Interventions included an advice sheet for rotating doctors, additional education at induction and a bone health proforma for medical notes and EDNs.

3. Results

86% of patients in cohort one had bone health plans in their notes and 59% in their EDN.  64% commenced on bisphosphonates with 1 eligible patient (4.5%) not receiving medication. After the interventions 100% patients had a bone health plan in their notes and 80% on their EDN. 46.7% of this cohort commenced bisphosphonates which equated to 100% of patients appropriate for bone protective medication.

Conclusion(s)

Providing guidance and education to rotating doctors to ensure Geriatrician-led bone health planning resulted in all eligible patients commencing bone protective medication and total numbers above the national average.

Introduction: The incidence of fragility fractures is rising with increased life expectancies. Most hip fractures require surgery. Acute kidney injury (AKI) is a preventable clinical syndrome that raises the risk of mortality. The aim of this study was to investigate the prevalence of AKI in hip fracture patients.

Methods: Data relevant to reported risk factors for developing AKI were collected before and after surgery within hip fracture patients in 2020. This included serum blood tests, anthropometric data, surgical factors and length of inpatient hospital stay.

Results: A total of 190 patients were included in this study. The pre-operative prevalence of AKI was 2.1%. The post-operative prevalence of AKI was 19.8%. The overall prevalence of AKI was 21.6%. Higher weight (p=0.046), increased length of hospital stay (p<0.001) and route of admission (p=0.046) significantly increased post-operative AKI. Mortality rate was significantly higher (p=0.002) in patients who developed AKI (59.5%) compared to non-AKI patients (29.8%).

Conclusion: Approximately one-fifth of all patients presenting with hip fractures in this study developed AKI peri-operatively, significantly increasing mortality rate. Obesity, inpatient hip fractures and longer hospital stay pose the highest risk of post-operative AKI. Close monitoring, early diagnosis and treatment are important for this vulnerable patient group.

INTRODUCTION 
 
Postural hypotension (PH) is an identifiable and potentially reversible cause of falls in the elderly patients admitted to hospital. The National Audit of Inpatient Falls recommends lying and standing blood pressure (LSBP) measurement for patients aged over 65. Our project aims to review current clinical practice and to develop a standardised approach to correctly investigate and manage PH in patients admitted following a fall to the geriatric department.
 
METHOD: 
 
We performed two cycles of retrospective data collection across three geriatric wards, looking at percentage of patients investigated for PH and the use of correct technique for LSBP measurements as recommended by the Royal College of Physicians (RCP) guidelines.

Between cycles, formal and informal educational strategies were implemented and the RCP LSBP measurement guidelines were displayed on doctors’ noticeboards and blood pressure monitoring devices. A PH sticker was designed to ensure correct technique was used and documented.
 
RESULTS:  
 
Following the interventions, the percentage of patients who had LSBP measurements performed improved from 28% to 96% [p<0.00001(X2 test)]. Introduction of the PH stickers improved use of correct technique from 12% to 37.5%. Performance and documentation of medication reviews for patients diagnosed with postural hypotension improved from 0% to 87.5% and lifestyle advice given and documented improved from 0% to 37.5%.  
 
CONCLUSIONS: 
 
Our study highlighted the need for further training on investigation and management of PH. Our results demonstrate that educational interventions and a standardised sticker to ensure clear documentation can significantly improve diagnosis of PH. The sticker and a patient advice leaflet have been approved by the local Falls Prevention Team and are now being processed by the Documents Control Team for official usage across all three Mid and South Essex sites. 

Introduction

The health benefits of owning dogs include improved physical activity, mental well-being, companionship, and so forth. However, musculoskeletal injuries caused by dog-related activities might negate the aforementioned benefits. The aim of this study was to estimate the number of femoral fractures directly linked to dog-related activities in people above the age of 60.

Methods

In this observational study, we included all patients above the age of 60 with femoral fractures caused by dog-related activities, over a one-year period (June 2022 to May 2023). We chose to include people above the age of 60 because they are more likely to have a fragility fracture and are entered in the National Hip Fracture Database.

Results

387 patients (above the age of 60) were admitted with femoral fractures during the study period. Of these, 16 were directly related to dog-related activities. The common mechanisms of injuries include being tripped, pulled down and jumped over by a dog, and tangled and tripped by the dog leash.

Conclusion

4% of femoral fractures (1 in 25) in people above the age of 60 were caused by dog-related activities. This is probably an underestimate, because some owners may not have volunteered this information out of love for their dogs and inadequate history regarding the circumstances that led to the fall. Despite the injuries, all patients still loved their dogs and wanted to go home as soon as possible to be with them. There were more fractures in spring and summer (11) compared to autumn and winter (5) which reflects increased activity with better weather. Having a dog is a risk factor for falls and fractures. We recommend that dog owners carefully consider their choice of dogs and if there are issues with handling them, both dogs and their owners should receive appropriate training.

Introduction

In the United Kingdom an average of 65,000 patients attend hospital with hip fractures each year, with 87% of these patients over the age of 70. Effective pain management is associated with significantly improved outcomes. Pain is known to be a significant trigger for delirium which itself greatly increases 1 year mortality and morbidity. Given the magnitude of the issue, this audit aimed to assess the effectiveness of an intervention in relation to the NICE National Standards for Neck of Femur (NOF) fractures at Weston General Hospital.

Methods

Data sets were collected from NOF fracture patients attending Weston General Hospital (WGH) Emergency Department (ED). The first data was from 29 patients between 4/4/2022-13/5/2022 and the second from 48 patients between 12/9/2022-22/2/2023. The red phone proforma in ED was amended in-between these data collections to include pain scoring and X-ray. Basic analysis allowed comparison between data sets.

Results

11.11% of patients had pain assessed within 15 minutes of arrival compared to 13.79% previously. For standard 2&3, 8.82% of patients had analgesia within 60 minutes, thus not meeting NICE targets. 93.18% of patients had an x-ray requested within 120 minutes compared to 62.07% previously.

Conclusion

Our results were very positive regarding X-ray time. However, the intervention did not improve pain assessment and analgesia time. Going forward, block training should be increased and more widely available in the ED given that only 33% of patients received one on admission. Additional consideration would be to edit the proforma to include pain re-assessment to closer meet NICE targets and improve patient care.

Toby Jack Ellmers (Imperial College London), Jodi Ventre (University of Manchester), Ellen Freiberger (Friedrich-Alexander-University Erlangen-Nürnberg), Klaus Hauer (AGAPLESION Bethanien Hospital Heidelberg/Geriatric Centre of the University of Heidelberg), David B Hogan (University of Calgary), Lisa McGarrigle (University of Manchester), Samuel Nyman (University of Winchester), Mae Ling Lim (Neuroscience Research Australia), Chris Todd (University of Manchester), Kim Delbaere (Neuroscience Research Australia), The World Falls Guidelines Working Group on Concerns About Falling

Background: Concerns (or, ‘fear’) about falling are common among older people. They have been reported to be associated with various negative outcomes, including activity restriction, depression, decreased quality-of-life and social isolation. Whilst prior conceptualisations have proposed an association between concerns about falling and future falls, the evidence base for such purported association is uncertain. We therefore conducted a systematic review to explore the association between concerns about falling and future prospective falls.

Methods: We searched 4 databases for articles that included concerns about falling as a baseline predictor for future falls over a 6-month period or longer. Following the removal of duplicates, we screened the abstract and titles of 10,554 articles; and the full text of 172 articles.

Results: We included and extracted data from 58 articles. A significant association between baseline concerns about falling and future falls was reported in 76% of the articles assessed (44/58); with higher concerns associated with a greater risk/odds of future falls. This significant association remained when controlling for confounding variables (n=16 articles).

Conclusion: These findings support previous conceptualisations and identify concerns about falling as an independent risk factor for future falls. As part of the World Falls Guidelines, we recommend that clinicians working with older people regularly screen for concerns about falling, using the short 7-item Falls Efficacy Scale-International (FES-I). Further analysis is currently ongoing to conduct meta-analyses based on specific outcomes (e.g., recurrent vs. single falls) and assessment tools (e.g., FES-I vs. single-item measures).