Digital Health

Introduction:

Many UK care home (CH) residents live with multiple long-term conditions, leading to high levels of healthcare utilisation. Previous studies have used routine data to describe their health and social care characteristics separately. Accurately identifying when an individual is admitted to a CH from routine data is challenging. This study aims to provide a combined health and social care profile of a cohort of long-stay CH residents, at the point of admission, using linked primary, secondary and social care data.

Methods:

Individuals aged 65 and over registered to a GP practice contributing to the ‘Connected Bradford’ dataset who were admitted to a CH between January 2016 and December 2019 were included. Start and end dates for social care packages (nursing and residential) were identified from local authority social care data. Respite and reablement packages were excluded. Complete self-funders were not identified with this method. Linked secondary and primary care data were used to describe health characteristics. CH residents identified using primary care records and local authority data will be compared.

Results:

2,801 individuals were admitted to a CH during the study period of whom 1998 (71%) were long-stay residents (>6 weeks). Only 72% of participants identified using local authority data, had a primary care code indicating CH residency in their primary care records. Median length of stay was 272 days (IQR 63 to 480). Mean age at admission was 85 years (SD 8), median Index of Multiple Deprivation decile five. 59% of residents required nursing care from admission. 79% of individuals were taking 5 or more medications.

Conclusions:

Using local authority data offers a novel way to identify and characterise CH residents. Linkage of primary care records to local authority data improves identification of CH residents using routine data. Additional linkage with address history would further improve accuracy.

Introduction

Information-sharing between primary and secondary care is vital for patient safety and reducing duplication. The Electronic Discharge Summary (EDS) enables this but is often incomplete due to time pressures and poor team continuity. Information from the Comprehensive Geriatric Assessment (CGA) by the Perioperative care of Older People undergoing Surgery (POPS) team is often omitted, leading to queries from primary care colleagues and duplication of work on readmission to hospital.

Methods

Eight core CGA components were determined for inclusion in the EDS. Twenty EDS were reviewed to for each PDSA cycle to assess compliance. Various strategies were trialled to increase compliance including junior doctor education (attendance at induction plus separate teaching), a checklist poster, the POPS team directly entering information into the EDS and a separate CGA summary.

Results

Baseline data demonstrated poor compliance with core CGA components (mean 25%, range 0-62.5%). PDSA 1 demonstrated improvement after junior doctor education and introduction of a checklist poster (mean 35%, range 12.5-87.5%). Mean compliance increased to 53% during PDSA 2 with the POPS team directly entering information into the EDS, but with continued wide variation (range 12.5 – 100%). The introduction of a POPS CGA summary to complement the EDS in PDSA 3 increased compliance with reduced variation in practice (mean 99%, range 87.5-100%).

Conclusions

Sharing information gleaned from a CGA was marginally improved with education, but is challenging due to the rotational nature of staff completing the EDS. The improvement seen with the POPS team entering EDS information was limited by the lack of 7-day working and the ‘locking’ of the completed EDS by the parent team. A separate CGA summary markedly improves information-sharing, with reduced variation in practice. This has benefitted primary and secondary care colleagues, as well as the POPS team when patients are readmitted or attend clinic.

Introduction

Patient and Public involvement is a cornerstone of the DREAM (Digital and Remote Enhancements for the Assessment and Management of older people) project. An advisory group of 10 diverse older people and carers was established to shape the research through regular discussions and explore inclusive involvement approaches for future work.

Methods

We conducted a reflective process evaluation to highlight the impact of the involvement process on the project and our public partners themselves. We collated impact logs, reflections and feedback from our public partners and an artist recorded the impacts using illustration.

Results

The advisory group:

• helped to lay the foundations of the project and steered its development with their views, knowledge and experiences
• shaped how evidence is captured and analysed so that it is usable, acceptable and makes sense to older people and carers
• provided insights to consider for implementation and shaped our dissemination strategy

Our public partners and researchers also expressed relational impacts such as shared ownership. Public partners joined this project to improve health care for other people. They felt safe to share their experiences and be listened to. It gave them confidence in their health management, and they have built friendships. People also found comfort in the diversity of individuals and sharing common concerns.

Conclusion(s)

Public partners have been instrumental in the development of the DREAM project and supported the programme by being a critical friend beyond the remit of the research. Continued communication and feedback resulted in public partners feeling heard and their suggestions acted upon.  Researchers and public partners felt gratitude, ownership and joy working on this project, and finding shared values. Our involvement approaches have shaped reciprocal relationships and had impact on our research culture, forming a foundation to the values of the people it is serving.

Introduction

The PROMOTe trial was conducted entirely remotely, which aimed to enable a wider recruitment of participants, minimise risk of Covid-19 exposure and adhere to former travel restrictions. Participant experiences with remote clinical trials are not well understood. This work aimed to characterise participant perspectives on the remote delivery of the PROMOTe trial.

Methods

The trial involved remote measurement of short physical performance battery and grip strength, and remote collection of stool, urine, saliva, and capillary blood. Equipment including a dynamometer was posted to participants. Participants returned biological samples by post. A mixed methods approach was used, whereby participants were invited to complete an online questionnaire consisting of Likert, multiple-choice and open-ended questions upon trial completion.

Results

Of 72 trial participants, mean age 73.1, 80.6% (n = 58) completed the questionnaire. 53.5% (n = 31) had no preference between remote or in-person participation. Of those who preferred to take part remotely, 57.1% (n = 4) stated this was because there was no need to travel. 57.1% (n = 12) of those who preferred to take part in-person stated this was because they preferred to talk to the staff and ask questions face-to-face. Participants found that taking 5 out of the 8 physical measures were of similar difficulty over video teleconferencing compared to in-person. 100% (n = 58) of participants found it “easy” or “average” to collect stool, urine, and saliva, while 63.2% (n = 36) of participants thought it was “easy” or “average” to collect capillary blood. All participants found packaging and returning all four sample types of “easy” or “average” difficulty.

Conclusion

These findings suggest that the majority of participants found remote trial delivery, including handling equipment and collecting biological samples, both acceptable and manageable. Remote trial delivery has potential for increasing access of older people to trial participation.

Introduction:Aging has been defined as a progressive, generalized impairment of function resulting in a loss of adaptive responses.Balance impairment is a major contributor to falling in elderly as efficiency of postural control system decreases with aging.Several different exercise programs have been suggested to address balance and falls in elderly.Virtual reality gaming and dual task training on balance may be an effective tool for addressing these problems because it includes different elements of balance which may improve functional mobility and is at the same time enjoyable and engaging.

Method:A total of 30 participants with the mean age of 67.63 ±4.32 years were included in the study, they were randomly divided in two groups. Group 1(Virtual reality Gaming) and Group 2(Dual task training).Both the groups received conventional therapy along with the specific interventions mentioned.The total duration of the intervention was 2 weeks and 5 sessions were given per week, each lasting for about 40 minutes.Pre and post-assessment for balance was assessed by scales including One-legged standing(OLS) test and Performance Oriented Mobility Assessment(POMA).The within-group comparison was made using Wilcoxon Signed rank test and between-group using the Mann Whitney U test to see the effect of treatment intervention.

Results:Within-group comparison for OLS and POMA showed statistically significant differences for the Pre and Post-intervention values (p<0.05).Between-group comparison demonstrated that Dual task training was more effective in improving the OLS balance as compared to virtual reality gaming (p=0.038).For POMA both the interventions were equally effective (p=1.00)

Conclusion:The study concluded that both Virtual reality Gaming and Dual task training were equally effective in improving balance when measured on POMA scale but Dual task training proved to be more effective in improving the OLS balance of the elderly when compared with Virtual reality.Therefore, we conclude that both the interventions can be used in improving balance of the elderly.

Introduction:Aging has been defined as a progressive, generalized impairment of function resulting in a loss of adaptive responses.Balance impairment is a major contributor to falling in elderly as efficiency of postural control system decreases with aging.Several different exercise programs have been suggested to address balance and falls in elderly.Virtual reality gaming and dual task training on balance may be an effective tool for addressing these problems because it includes different elements of balance which may improve functional mobility and is at the same time enjoyable and engaging.

Method:A total of 30 participants with the mean age of 67.63 ±4.32 years were included in the study, they were randomly divided in two groups. Group 1(Virtual reality Gaming) and Group 2(Dual task training).Both the groups received conventional therapy along with the specific interventions mentioned.The total duration of the intervention was 2 weeks and 5 sessions were given per week, each lasting for about 40 minutes.Pre and post-assessment for balance was assessed by scales including One-legged standing(OLS) test and Performance Oriented Mobility Assessment(POMA).The within-group comparison was made using Wilcoxon Signed rank test and between-group using the Mann Whitney U test to see the effect of treatment intervention.

Results:Within-group comparison for OLS and POMA showed statistically significant differences for the Pre and Post-intervention values (p<0.05).Between-group comparison demonstrated that Dual task training was more effective in improving the OLS balance as compared to virtual reality gaming (p=0.038).For POMA both the interventions were equally effective (p=1.00)

Conclusion:The study concluded that both Virtual reality Gaming and Dual task training were equally effective in improving balance when measured on POMA scale but Dual task training proved to be more effective in improving the OLS balance of the elderly when compared with Virtual reality.Therefore, we conclude that both the interventions can be used in improving balance of the elderly.

Introduction: Following COP26, the NHS pledged a ‘Net Zero’ health service by 2040. Incineration of clinical waste has a negative impact on the environment whilst also being extremely costly. NHS Grampian spends over £1m annually on disposal of clinical waste, whilst 20% of the waste incinerated is unsuitable for that waste stream. An excess of clean plastic packaging from visors, used when managing respiratory viruses, was a particular contributor in our unit. To improve sustainability, the aim of this quality improvement project was to reduce unnecessary disposal of plastic packaging in clinical waste streams by 80% in our Geriatric Assessment Unit.

Method: Using PDSA methodology, data was collected regarding the number and location of clinical waste bins and how many contained plastic visor packaging or any form of ‘non-clinical’ waste. Qualitative data highlighted that staff were aware of disposing waste in the wrong stream, however, struggled to find alternative waste bins located nearby. Selected orange bins were removed and black bins introduced at convenient points. Further PDSA cycles focused on staff engagement and education.

Results: Following PDSA Cycle 1, a baseline median of 57% of orange bins contained clean plastic packaging and 64% contained any form of non-clinical waste. Following staff education, clinical waste bins containing single use plastic dropped to 0%, whilst the percentage containing any form of non-clinical waste remained averaging 35%.

Conclusion: Making clinical waste bins less readily available reduces the amount of unnecessary clean plastic packaging entering clinical waste. We must counteract this through increasing access to general and recyclable waste bins to ensure waste is disposed of correctly. This may be achieved through the creation of “waste stations” in preparation areas, to facilitate readily available access to all waste streams at a single point if required.

Background

The Ageing Well programme within the NHS Long Term Plan promotes person-centred care aligning  with the goals of Integrated Care Systems (ICSs) in unifying health and social care aiming to increase the proportion of care to older people delivered in the community (NHS England, 2019). As most older people admitted to hospital are conveyed by ambulance services this presents a focus to reduce hospitalisation (Maynou L, Street A, Burton C, et al. Emergency Medicine Journal 2023).

North Central London ICS has invested in ‘Silver Triage’ a pre-hospital telephone support scheme which sees geriatricians and emergency physicians supporting the London Ambulance Service in their clinical decision making relating to older people at the point of assessment.

Methods

Data from the first fourteen months of the scheme was analysed.

Results

Between November 2021 and January 2023 there have been 452 Silver Triage cases with 80% resulting in a decision to not convey an older person to hospital. The mode clinical frailty scale (CFS) score was 6 with no difference in conveyance rates based on CFS. Prior to triage paramedics thought hospitalisation was not needed in 44% of cases (n=72/165). Most paramedics (93%, n=154/165) found it easy to contact the team with all 176 who responded to a post triage survey answering they would use it again. Many (66%, n=108/164) felt they learnt something from the discussion, with 16% (n=27/164) reporting it changed their decision-making process.

Conclusion

Silver Triage has the potential to improve the care of older people by preventing unnecessary hospitalisation and has been well received by paramedics.

Background: Hospital Electronic Health Records (EHRs) increasingly capture health and functional deficits. We report outcomes for acute cardiac patients in relation to an automated frailty measure derived from these EHR data.

Methods: We conducted a retrospective observational cohort study of consecutive cardiology admissions aged ≥70 years between April 2016 and August 2020, to three hospitals across Edinburgh, Scotland. The Continuous Dynamic Evaluation of Frailty (CODE-f) is an automated score between 0 (no markers present) and 1 (all present) representing 12 deficits generated from 31 admission EHR data points. This includes measures of cognition, functional dependence, mobility and falls risk. The primary outcome was mortality at 1 year. The secondary outcome was days alive and out of hospital (‘home time’) in the year after discharge for hospital survivors. In a nested cohort of 318 consecutive patients, the Clinical Frailty Scale (CFS) was determined from manual EHR review blinded to CODE-f scores.

Results: 2,406 patients were included (mean 79±6 years old, 60% male). A CODE-f score could be generated in 2,158 (90%) patients, with a median score of 0.13 (IQR 0–0.33). There were 352 (15%) deaths by 1 year. Patients in the highest CODE-f quartile (>0.35) had three times greater risk of death at one year than in the lowest quartile after adjustment for age and sex (27% versus 9%, adjusted odds ratio 3.44, 95% CI 2.47–4.82, p<.001). 16% of patients from the highest CODE-f quartile lost>90 days home time in the year after discharge, compared to 6% in the lowest two quartiles (p<.001). CODE-f scores correlated moderately well with CFS (spearman’s r="0.50," 95% ci 0.41–0.58, p<0.001).

Conclusion: An automated EHR measure can identify older adults at risk of death and poorer recovery after acute cardiac illness. This could inform treatment decisions future care planning.

Funding: Chief Scientist Office (pcl />18/05)

 Introduction In the presence of multiple co-morbidities and frailty, older people undergoing emergency laparotomy warrant higher supportive care. It is evident that geriatrician input to perioperative care plays a crucial role to improve patient experience and outcomes ( 1, 2). Whilst we recognised the need for a surgical liaison service and increased compliance with NELA we had limited resources to give. We created an automatic email alert to enable us to see NELA patients and make the maximum use of our clinical time. Method An automated email alert was created in July 2022 to identify patients undergoing laparotomy based on theatre coding, we then set up filtering by age and frailty. A surgical liaison service was already established but we were able to target NELA patients from September 2022. Retrospective analysis of local data for Morriston Hospital extracted from 2022 National Emergency Laparotomy Audit allowed comparison of compliance to expected standards by the SOPAS (surgical liaison) service before and after intervention. Results There were 225 patients who required emergency laparotomy at Morriston hospital in 2022. 50 patients met NELA criteria of which 30% were > 64 with high CFS and 70% over 80. A 3 month period (March-May) prior to the intervention and 3 months following (Sept-Nov). We showed an increased in compliance with NELA standards from under 10% to over 50% with this intervention. Conclusion Significant improvement of 5% to 50% compliance with NELA standards was observed after the intervention of email alert; further to this we noted an issue with the alert working through December 2022 where many patients were not seen. This corresponded with a period of increased mortality. Our aim going forward is to upscale this to align with the BGS Position Statement. (3

Introduction

People with Parkinson’s disease (PwP) are more likely to be admitted to hospital and have longer lengths of stay than those without Parkinson’s disease (PD). Parkinson’s UK and NICE have proposed standards of care for inpatients with PD, including that PD specialists are alerted when PwP are admitted to hospital. 66% of UK hospitals don’t have an alert system in place, including King’s Mill Hospital (KMH).

Audit

Over a 6 month period, referrals to the PD service in KMH were audited. 128 referrals were made; 5 per week on average. Hospital-wide, around 12 PwP are admitted weekly. Therefore under 50% are referred for specialist input. 64% of patients had been in hospital over 24 hours before referral. 16 patients were referred to the PD service more than once during admission, reflecting ongoing management difficulties.

Intervention

The digital transformation team completed software changes to create an electronic alert when PwP are admitted to hospital. The local system for recording admission details and electronic prescribing, NerveCentre, can now generate an electronic list showing all inpatient PwP. A multi-disciplinary virtual PD ward round was introduced. Using NerveCentre, all PwP can be remotely reviewed and triaged. Proactive, positive interventions from the specialist PD team include: constipation management, osteoporosis screening, speech and language therapist review, cognitive assessment, issuing dysphagia cards, and advance care planning. NerveCentre enables remote medication reviews and audit of prescribing, ensuring that any breaches of the ‘Get It On Time’ campaign are reported via Datix, with relevant learning shared. The virtual ward round provides training opportunities for specialist registrars, junior doctors, and newly appointed PD specialist nurses.

Conclusion

The electronic flag permits more comprehensive, proactive and timely inpatient reviews of PwP. The interventions from this project enable the Trust to meet Parkinson’s UK recommendations and hopefully improves the inpatient experience of PwP.