Bone Health

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.

Introduction: The number one reason for older people to be taken to hospital emergency departments is a fall¹. An “Ambulance Improvement Programme Pillar”² is trying to reduce conveyance to hospital for falls, however it is not understood how the attending clinician’s confidence impacts decision-making.

Objectives:

1.  Assess recruitment rate.

2.  Assess feasibility of online survey delivery.

3.  Determine the experiences and confidence of frontline emergency clinicians in attending older adults who have fallen.

Method:

Online cross-sectional survey, undertaken in one English ambulance service in May 2023. 

Demographics were collected from participants about their role, along with 5-point Likert scales of confidence.

Data were summarised using descriptive statistics and Chi-square analyses to compare confidence between localities and years’ experience.

Results:

81 responses were received from across the regional ambulance service’s 16 localities.

76% of respondents were paramedics, other respondents were emergency medical technicians and student paramedics.

53% were aged 25-34.

60% of respondents rated being ‘somewhat confident’ to ‘How confident do you feel in assessing older adults who have fallen?’, responses ranged between ‘Neither confident nor unconfident’ to ‘Completely confident’.

No significant difference was found between the locality and confidence levels for assessing this patient population. However, there was a significant difference between confidence levels when utilising hospital avoidance pathways across localities (p-value=.0045). 

Length of experience in either frontline ambulance and overall healthcare provision was not significantly associated with different levels of confidence.

Conclusion: Locality of work had a relationship with confidence in utilising hospital avoidance pathways. In contrast, locality of work did not significantly impact confidence to assess older adults who have fallen. Confidence levels were not found to be related to the number of years providing healthcare. Online survey delivery is feasible effective method in this population.

References

1. Dewhirst. (2023). National Falls Prevention Coordination Group. https://committees.parliament.uk/writtenevidence/117837/pdf/

2. NHS England and NHS Improvement. (2019). Ambulance Improvement Programme. https://www.england.nhs.uk/wp-content/uploads/2019/09/planning-to-safetly-reduce-avoidable-conveyance-v4.0.pdf

Older people with diabetes are often admitted with falls, dizziness or confusion that may stem from undiagnosed episodes of hypoglycaemia. We examined the use of a 10-day period of round the clock glucose monitoring (CGM), to detect hypoglycaemia in older people with diabetes with symptoms potentially related to hypoglycaemia. 

Methods 

Population: Age 75 years and older, on sulfonylureas and/or insulin, presenting to hospital with a fall and/or symptoms suggestive of unrecognised hypoglycaemia. 

Design: Single-centre, observational study (no change to standard diabetes care). Intervention: 10 days of CGM with Dexcom G6 sensor and Android app on smartphone to continuously transmit data. 

Primary outcomes: Proportion of participants with captured hypoglycaemia; within that group, time spent in the hypoglycaemic range (Battelino T, Danne T, Biester T, et al. Diabetes Care. 2019;42(8):1593-603.). 

Secondary outcomes: Overall time in range; emergency department re-attendances and/or hospital re-admissions for falls, fractures, heart attacks, ischaemic strokes and death within 30 days. REC IRAS project ID: 301286. 

Results 

26 eligible participants of which 13 consented to participate. At the time of writing, nine participants (mean age 81 years) completed the study.

There were no reports of pain or skin reactions from the participants.

Hypoglycaemic events were captured in 3 of 9 participants, with two participants suffering >1 hour below 3.9mmol/L. Only 3 participants achieved >50% time in range target (3.9-10.0mmol/L). 

Discussion 

We have detected significant hypoglycaemic episodes in our participants. CGM should be used more widely in older patients with diabetes who present with falls, dizziness or confusion. 

Limitations include issues around data capture due to participants struggling to navigate the mobile phone app. Despite this, all participants felt that CGM was better than finger-prick glucose testing. Future work is needed to explore how CGM can be deployed after acute admissions in this patient group.

Introduction

Reduction in outpatient appointments during the COVID-19 pandemic and patient concern surrounding risk of contracting COVID-19 by attending day-case settings, resulted in delayed or cancelled medical treatments including Zoledronic Acid infusions as management for Osteoporosis. This, alongside recent research concluding that these treatments can be given safely as early as 1-2 weeks post-fracture, lead to the adaptation of protocol at Hull University Teaching Hospitals Trust in 2021, to provide rapid loading of Cholecalciferol over 6 days, prior to administration of Zoledronic Acid on day 7. However, some concerns remain surrounding the potential interference with bone remodelling and healing. This completed audit cycle evaluates the logistics and safety of this new protocol.

Methods

All patients over 60, admitted with neck of femur fracture who received Zoledronic Acid infusion as inpatient or outpatient in 2019 and 2021 were included in the initial and repeat audit respectively. Electronic records for the following 12 months were analysed evaluating for further fragility fracture and mortality rate.

Results

There was an increase in patients receiving Zoledronic Acid as an inpatient treatment from 21% in the initial audit to 97% in the repeat audit. There was a slight increase in mortality rate at one year from 14% to 19%. The percentage of a further fragility fracture within one year, remained stable at 7%.

Conclusion

The increase in inpatient infusions suggests more patients with significant frailty who would otherwise not have been able to attend outpatient settings, have been able to receive treatment. The mortality results reflect this frailer audit population. The absence of a substantial increase in the rate of further fragility fracture at one year; supports the earlier administration of Zoledronic Acid as a management protocol.

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  

People with Parkinson’s (PWP) are twice as likely to fracture and over twice as likely to develop osteoporosis (1. Henderson et al, Parkinsonism & Related Disorders, 2019, Vol.64, pp.181-187). This is associated with significant morbidity (1). Assessment of bone health is often overlooked in clinic (2. UK Parkinson’s Excellence Network, 2019, pp.4-56), deeming it a priority area for improvement. Our project focuses on implementing routine bone health assessment for PWP in clinic, to achieve better standards of care.  

Methods  

This was a 12-week medical student led project, supported by the specialist multi-disciplinary Parkinson’s team (MDT) in Cardiff and Vale. To establish baseline current practice, a retrospective fracture risk assessment was completed for 141 patients using the Bone-Park algorithm (1). To screen bone health, we developed a bone health proforma, incorporating the FRAX tool. We trialled proforma integration in clinic, by gaining patient feedback and analysing logistics. Administration was done in a patient, healthcare assistant (HCA) and clinician led format.  

Results  

The retrospective analysis showed that 61.7% (n=87/141) of patients required bone health intervention. Of these patients, 41.4% required vitamin D supplementation. 40.2% required bone density measurement. 18.4% required bone strengthening treatment. This was subsequently initiated. Issues identified with self-administered forms (n=8/30) were physical difficulty in completing forms and confusion around medical terminologies, which clinician led administration (n=14/30) could support. HCA’s (n= 8/30) required MDT support to complete forms. 

Conclusion  

As PWP have an increased fracture risk (1), our results provide compelling evidence that routine bone health assessment should be better integrated into Parkinson’s management. Clinician led administration of our proforma was the best model of integration. This was based on patient preference, a reduction in duplication and improved accuracy. Further bone health education is needed within our MDT, which we aim to incorporate through our Parkinson’s web application.   

Introduction

The patients most often admitted with a hip fracture are older adults, many of whom are frail. The Scottish Hip Fracture Standards recommend that all patients have fluid assessment and are mobilised by the end of day 1 post operatively. We set out to look to see which patients are most at risk of acute kidney injury (AKI) and orthostatic hypotension (OH) post operatively and whether this was linked to the prescription of iv fluids (IVF).

Method

All online notes of patients admitted with a hip fracture in the months of July and November 2022 were reviewed. Notes were reviewed for type of anaesthesia (General Anaesthetic or spinal), frailty score (using Rockwood), presence of AKI on days 1-3 post operatively (as determined by looking at lab results), and presence of orthostatic hypotension on days 1-3 post operatively (as documented in physiotherapy notes).

Results

There were 120 patients audited (July: 59; November: 61). 39 patients had IVF prescribed post operatively, 15 developed orthostatic hypotension and 20 developed an AKI. The frailest patients (Rockwood 6/7) were most likely to be prescribed fluids post-operatively (25/52) however had the highest rate of AKI (12/52). Moderately frail patients (Rockwood 4/5) were less likely to be prescribed IVF (8/42) and most likely to develop orthostatic hypotension (9/42) even compared with the frailest patients (3/52). This did not differ by operation type as the same proportion received IV fluids with a spinal (11/30) or general anaesthetic (28/86). Antihypertensives were not linked to AKI but were to OH.

Conclusion

Moderately frail patients are the group that appear most likely to develop post operative orthostatic hypotension but are not prescribed post operative fluids as frequently as the most frail. This may be leading to increased risk of orthostatic hypotension and thereby delay rehabilitation in a vulnerable group.

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).

Background

Hip fracture in the elderly is associated with significant morbidity and mortality. These patients often have serious co-morbidities, including cardiac conditions, and are at risk of developing perioperative decompensation. Heart failure represents a common and serious perioperative condition in hip fracture patients1. We conducted a quality improvement project to identify incidence of perioperative pulmonary oedema and the possible risk factors.

Method

Retrospective analysis of patients aged 60 years and older admitted with hip fracture over a one month period. Perioperative period was taken as time from admission to day 5 post surgery. Intravenous fluids administered pre-op, intra-op and for 5 days post-op were reviewed. Pulmonary oedema was diagnosed on clinical and radiological findings.

Results

50 patients admitted: 14 (28%) male; 36 (72%) female. Mean age: 82 years, 94% (47) admitted via emergency department. Comorbidities: 48% hypertension, 30% atrial fibrillation/flutter, 18% cardiac failure, 14% dementia. Pre-operative clinical review identified 14 (28%) patients as high risk for developing cardiac decompensation perioperatively. 57% (27/47) of patients admitted via accident and emergency received intravenous fluids pre-operatively. None of these patients had vital signs suggestive of hypovolaemia. Rate of fluid administration: 10/27 (37%) 1 litre over 4 hours, 5/27 (22%) 1 litre over 2 hours, 2/27 (7%) 1 litre over 1 hour. Intra-operatively 43 patients (86%) received intravenous fluids, 18 patients (36%) received ≥ 2 litres of fluid. 6 (12%) patients developed pulmonary oedema in the perioperative period

Conclusion

Fluid overload in our cohort may be an underestimate as many patients were anticipated to be at high risk of developing pulmonary oedema with consequent very careful fluid management and diuretic administration. Intravenous fluid administration requires careful assessment and monitoring in elderly hip fracture patients.

References

1. Michael W Cullen 1 , Rachel E Gullerud, Dirk R Larson et al J Hosp Med 2011 Nov;6(9):507-12.