Cardiovascular

Introduction: It’s estimated that 52% of elective vascular patients are frail, with predictions by 2030, one-fifth of surgical procedures will involve patients over 75. This project aimed to evaluate current practices around frailty recognition and documentation at the South-East Wales Vascular Network's regional surgical centre.

Objectives:

Assess the proportion of patients >65 years with documented frailty assessments using the Clinical Frailty Scale (CFS).

Assess healthcare workers' understanding of frailty and familiarity with the CFS. Identify barriers to recognising and undertaking frailty assessments.

Provide a frailty-focused educational intervention for the multidisciplinary team.

Methods: Data was collected prospectively for 22 patients >65 over two weeks in March 2024. The project team reviewed whether a CFS score was recorded on electronic workstation and independently completed a CFS score. Teaching sessions were organised for the multidisciplinary team on frailty recognition and CFS use. Pre- and post-teaching questionnaires gauged confidence levels in using the CFS.

Results: Out of 22 patients, 10 had recorded CFS scores, with 6 being accurate. For the 12 patients without recorded scores, 8 were classified as frail. The mean age was 76 years. The questionnaire revealed knowledge gaps: none of the nurses knew where to document a frailty score, and only 33% of physiotherapists and 60% of occupational therapists knew where to record a CFS score. Post-teaching, staff confidence in frailty recognition increased significantly.

Conclusions: Identifying frailty enables better perioperative risk assessment and surgical decision-making. Frailty documentation on Ward B2 is inadequate. Data collection highlighted nurses' lower awareness of frailty scoring, necessitating further improvement cycles. 73% of patients were frail, with 36% not previously identified as such. Improving frailty recognition will enhance care planning for frail patients undergoing vascular surgery. Designating a 'Frailty Champion' could improve frailty score documentation and ensure its routine inclusion in assessments on Ward B2 at UHW.

Introduction Hospital-at-Home (HaH) is an innovative care model delivering hospital-level care to community patients. A key priority for Bromley HaH has been to streamline strategies, providing integrated, individualised care for patients with heart failure (HF). Our study revealed that our length of stay (LOS) exceeded the 7-day target, and readmission rates surpassed the 0-10% target. Recognising the complexities of managing HF in the community, we evaluated the impact of a new HF bundle to enhance clinician confidence, reduce LOS, and improve outcomes and service capacity. Method An adapted HF bundle was developed in collaboration with local cardiologists to integrate services. The bundle included standardised assessment/management tools, technology-enabled care (point-of-care and remote monitoring), and clear discharge criteria. It was implemented alongside departmental teaching, HF clinic/MDT attendance for experiential learning, and weekly consultant-led MDMs to build confidence. Retrospective data was collected before and after the bundle's introduction to assess impact on LOS and readmission rates. Results Between February 2023 and May 2024, 48 unique patients were seen (mean age 81, 28 hospital step-downs, 20 community step-ups). Initial clinician surveys showed 83% lacked confidence, 75% struggled with diuretic titration, and 60% unsure about optimising prognostics. Baseline data from February 2023 to January 2024 showed an average LOS of 13 days and a readmission rate of 15.7%. Post-bundle implementation, average LOS reduced to 10.95 days, and readmission rates dropped to 7%. Clinician surveys reported increased confidence, and over 90% of service users rated their care as excellent. Conclusion The implementation of our HF bundle significantly improved clinician confidence, halved readmission rates, and reduced LOS, thereby increasing patient throughput and service capacity, and achieving a 41% reduction in cost per bed-day. The study also contributed to the development of a dashboard to continuously monitor the effectiveness of these interventions and highlight areas of further development.

Introduction

Venous thromboembolism (VTE) risk following acute stroke is high. Current guidelines recommended intermittent pneumatic compression (IPC) stockings for up to 30 days in those who are immobile following acute stroke. The concern post-stroke is haemorrhagic complications when using low molecular weight heparin (LMWH). The CLOTS3 trial favoured IPC for safety in the first 30 days. However, in many cases, doses suitable for VTE prophylaxis can be used but with caution if IPC cannot be used.

Method

A spot audit of patients current VTE prophylaxis was undertaken in a stroke rehabilitation unit to look at IPC and LMWH usage. 10 patients were selected at random to look retrospectively at choice of VTE prophylaxis and how this changed during their admission.

Results

35 patients' full records were available. Five patients were within 30 days of admission. 12(34.3%) were anticoagulated, predominantly for atrial fibrillation. 15(42.8%) were on LMWH. VTE prophylaxis was not indicated in 3(8.6%) patients. 5(14.3%) were on no VTE prophylaxis. Of the 10 patients reviewed in depth 7(70%) had used IPCs for a time during their admission. IPCs were discontinued in 3 after starting anticoagulants and in 4 at the patients request. In 3 of the patients where IPCs were not tolerated there was a delay in starting an alternative form of VTE prophylaxis. Complex decisions were required in a patient started on LMWH post-neurosurgical intervention.

Conclusions

Decisions regarding VTE prophylaxis following acute stroke are complex. Changes are required frequently during inpatient admission and delays occur both on admission and when non-specialist team members are not confident in prescribing an alternative to IPCs. We would recommend a prompt to ensure VTE prophylaxis is considered on initial ward round and regular review during admission with anticipatory consideration of an alternative to IPCs by specialist clinicians if they are subsequently not tolerated.

Introduction :

Pulmonary hypertension assessed by echocardiography in patients with COVID-19 has not been adequately studied and it is unknown precisely whether it is linked to worse outcomes.

Materials and Methods :

Retrospective study of 306 adults infected with COVID-19 by antigenic or molecular testing. The main objective was to evaluate the role of the probability of echocardiographic pulmonary hypertension and its relationship with morbidity and mortality according to the ROX index in patients with COVID-19 infection. In the inferential statistical analysis, the OR odds ratios with their confidence intervals greater than 95% were used as measures of association. Qualitative variables were evaluated using the Chi square test or Fisher's exact test, and in the case of numerical or quantitative variables, the Student's T test or Mann-Whitney test was used.

Results :

The highest frequency in gender was Male 78% and Female 22%, the ROX values were higher in survivors at 2 h 5.8 (4.7 - 6.9), in relation to the deceased 4.5 (3.6 - 5 ,6). Likewise, at 12 h the values were higher in the group of survivors 7.8 (5.2 - 8.7) in relation to the deceased 4.9 (3.8 - 6.0). The odds ratio adjusted for age and gender of the ROX index was 8.5, CI (2.0 - 91.4) at 2 h and 17.6, CI (2.8 - 93.6) at 12 h. A statistical correlation was evident between lower values of the ROX index with values of high probability of pulmonary hypertension (p=0.048) as well as higher mortality (p=0.037).

Discussion :

The present study showed a correlation between the ROX index with pulmonary pressure values estimated by transthoracic echocardiogram and older age groups, showing higher mortality in those over 70 years of age and a higher rate of comorbidities and lower ROX.

Conclusions:

A greater probability of pulmonary hypertension is linked to high mortality in COVID-19; studies with larger groups of patients are required to validate the results found here.

Introduction:

Metabolic syndrome has been associated with an increased risk of cancer. This study evaluated this association in a South American cohort.

Methods:

Retrospective observational study in 100 patients older than 60 years with metabolic syndrome for more than 10 years from a hospital outpatient center. Anthropometric (waist circumference, body mass index), biochemical (triglycerides, HDL cholesterol, fasting glucose) and clinical (arterial hypertension, type 2 diabetes mellitus) parameters were evaluated. The association between metabolic syndrome, its components and cancer risk was analyzed using proportional hazards and chi-square models.

Results:

A statistically significant association was found between abdominal obesity (average waist circumference of 103.8 cm and BMI of 36.05), hypertension and hyperglycemia with an increased risk of cancer. The highest prevalence of cancer occurs in people over 60 years of age. In this group, 72.1% of the cases of the disease are diagnosed in men and 65.8% in women. A higher risk is reported in patients with grade I obesity (BMI 30-34 kg/m2.

Conclusion:

MS is strongly associated with increased cancer risk in older South American adults, especially due to central obesity, hypertension and hyperglycemia.

Introduction:

Assessment of lying and standing blood pressure is commonly undertaken in geriatric medicine to make a diagnosis of orthostatic or postural hypotension. We carried out the audit to review the clinical practice and assess its adherence to the Royal College of Physicians (RCP) guidance on how to accurately measure the lying and standing blood pressure (Falls and Fragility Fracture Audit Programme).

Method:

It was a prospective audit. The first audit cycle was conducted in July 2020 and the second cycle in April 2021

Results:

During the first data collection, the practice was reviewed in 69 patients. 35 were female (age range 63-92 years) and 34 male (age range 72-95 years). The lying and standing blood pressures were measured in 27 patients. Only 4 were performed as per the RCP guidance. 34 team members (including doctors, nurses, healthcare assistants, etc.) were randomly surveyed on how to correctly measure lying and standing blood pressure. None were aware of the RCP guidance in this context. We delivered local presentations of the results of the audit and RCP guidance flyers were displayed on the bulletin boards in the department. During the second cycle, the practice was reviewed in 58 patients. 30 were female (aged 67-94 years) and 28 male (aged 68-96 years). The lying and standing blood pressures were measured in 32 patients, of which 20 were recorded according to the RCP guidance. There was an increase of adherence to the guidance from 14.8% to 62.5% after undertaking the aforementioned interventions.

Conclusions:

Following dissemination of the RCP guidance on how to accurately measure the lying and standing blood pressures, we witnessed an improvement in the practice suggestive of an improved clinical effectiveness. Robustly evaluating a service followed by education of the staff can lead to enhanced clinical care and quality improvement.

Introduction: A growing body of evidence suggests that metabolic syndrome is associated with endocrine disorders, including thyroid dysfunction. Thyroid dysfunction in patients with metabolic syndrome may further increase the risk of cardiovascular disease, thus increasing mortality. This study was conducted to assess thyroid function in patients with metabolic syndrome and to assess its relationship to components of metabolic syndrome.

Methods: A cross-sectional study was carried out among 170 geriatric patients. Anthropometric measurements (height, weight, waist circumference) and blood pressure were taken. Fasting blood samples were analyzed for glucose, triglycerides, high-density lipoprotein (HDL) cholesterol, and thyroid hormones (triiodothyronine, thyroxine, and thyroid-stimulating hormone).

Results: Thyroid dysfunction was observed in 31.9% (n = 54) of patients with metabolic syndrome. Subclinical hypothyroidism (26.6%) was the main thyroid dysfunction followed by overt hypothyroidism (3.5%) and subclinical hyperthyroidism (1.7%). Thyroid dysfunction was much more common in women (39.7%, n=29) than in men (26%, n=25), but not statistically significant (p=0.068). The relative risk of having thyroid dysfunction in women was 1.525 (CI: 0.983-2.368) compared to men. Significant differences (p = 0.001) were observed in waist circumference between patients with and without thyroid dysfunction and HDL cholesterol that had a significant negative correlation with thyroid-stimulating hormone.

Conclusion: Thyroid dysfunction, particularly subclinical hypothyroidism, is common among patients with metabolic syndrome and is associated with some components of metabolic syndrome (waist circumference and HDL cholesterol).

Introduction:

Atrial Fibrillation (AF) causes 15% of ischaemic strokes. The National Clinical Guideline for Stroke recommends at least 24 hours of cardiac monitoring and a longer duration if cardio-embolic stroke is suspected. The British Heart Rhythm Society suggests up to 72 hours of cardiac monitoring. Currently, there is little data on the use of telemetry in detecting AF in acute strokes.

Aims:

Our study aims to evaluate the detection rate of new onset AF in acute stroke with telemetry and to determine if there was any correlation between the duration of telemetry and the detection rate of AF.

Methods:

All patients with ischaemic stroke who were admitted to stroke ward over a 3-month period were retrospectively analysed. Exclusion criteria were patients who were known to have AF, had new AF on admission electrocardiogram, patients receiving palliative care, patients who were discharged home early without having a telemetry and patients with missing records.

Results:

61 patients met the inclusion criteria and 5 (8.2%) had AF on telemetry. Two patients had AF on day 1, one on day 2 and two on day 3. All of these patients were anticoagulated. The duration of telemetry ranged between 1- 19 days however no AF was detected beyond the third day of this study.

Conclusions:

AF was detected in 8% of patients with ischaemic stroke within the first 72 hours of admission. Among the patients in whom AF was detected, 5% were detected between 24 hours and 72 hours of admission. Studies (EMBRACE and CRYSTAL trials) have shown that prolonged cardiac monitoring (30 days and 6 months to a year respectively) resulted in higher detection rates of AF. This study suggests that patients with ischaemic stroke should be monitored for at least 72 hours due to a higher detection rate of AF.

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. 

The 2022 national heart failure audit noted, "Older patients are less likely to access diagnostics, lifesaving drugs, and specialist care.” Additionally, there is evidence suggesting that they are less frequently initiated on disease-modifying drugs (DMD). The National Institute for Health and Care Excellence (NICE) supports the use of SGLT2 inhibitors for those with heart failure with reduced ejection fraction (HFrEF). However, this has recently expanded to those with preserved ejection fraction (HFpEF). This is significant for elderly heart failure patients as SGLT2 inhibitors offer a favourable side effect profile. 

Our research was conducted in 2022 at a tertiary hospital. This research involved the analysis of thirty-eight heart failure patients that were admitted under the care of the geriatric medicine team. We investigated the initiation of diagnostics, the utilisation of DMDs and the coordination of post-discharge follow-up arrangements. 

Our study revealed significant inconsistencies with the management of heart failure within this patient demographic. Notably, a substantial proportion of patients lacked prescriptions for DMDs, and the initiation of SGLT2 inhibitors was inadequate. Moreover, over 62% of patients did not receive scheduled follow-up appointments. We also found that a considerable number of patients missed essential diagnostic echocardiograms, which are critical for determining the appropriate DMD prescriptions.

These results highlight the urgent requirement for improved education and access to diagnostics and DMDs. We plan to share our findings at the forthcoming local geriatric meeting and aim to collaborate more closely with the cardiology department to enhance care quality and integration.