Education

INTRODUCTION: Medical students may find practical aspects of the transition to FY1 doctor challenging. In recent years medical curriculums have been updated to address this issue by increasing the emphasis on assistantships and practical learning. We explored how prepared final year medical students felt for managing common scenarios in geriatrics, such as a patient with delirium or inpatient falls. This allowed us to develop a tailored teaching programme to be delivered by junior doctors with relevant practical experience.

METHODS:

1) We surveyed assistantship students in geriatrics to identify areas in which knowledge and confidence were lacking. We subsequently developed a tailored teaching programme to address these gaps, focusing on practical tasks and common scenarios.

2) We delivered teaching to 3 sets of assistantship students, each receiving two teaching sessions per week for their 4 week placement.

3) Quantitative & Qualitative (Likert Scale) feedback was sought using a standardised feedback form. We used QI methodology to update and improve our curriculum & delivery to match students’ learning needs.

RESULTS:

• Over the course of the teaching programme, 89 feedback forms were completed.

• 54.8% of students felt “unprepared” or “somewhat unprepared” whilst only 18% felt “prepared” or “somewhat prepared”.

• Following the teaching session, only 2.3 % felt “unprepared” or “somewhat unprepared. Those feeling “prepared” or “somewhat prepared” improved to 92%.

• 91% found the teaching relevant to their learning needs. • 91% rated teaching quality 5/5.

CONCLUSIONS: Students felt ill-equipped to manage many practical aspects of FY1. Junior Doctors are uniquely placed to address the practical knowledge gaps final year medical students may have. Our teaching programme greatly improved the students’ confidence on practical tasks and scenarios commonly encountered while working as an FY1 doctor. It was a valuable supplement to assistantship placements, and will be incorporated for future years.

Introduction

Authoritative medical organisations including the Resuscitation Council UK, NHS and BMA all state that Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions should only be relevant to CPR and should not impact other decisions about care and treatment. We set out to examine the reality of decision making in clinical practice.

Methods

We circulated a clinical scenario of a patient deteriorating with COVID-19 after hip fracture to 128 members of the consultant and trainee geriatrician WhatsApp groups in Wales. Recipients were blindly randomised to one of two versions; differing only in whether or not they included the words “She has a DNACPR in place”. Recipients were unaware of the survey’s purpose. We surveyed individuals’ management decisions using a multiple-choice Likert scale questionnaire.

Results

A total of 47 (37%) clinicians responded. Those who addressed the scenario without a DNACPR decision were more likely to consider non-invasive ventilation (91% vs 67%, P<0.05), and more likely to consider escalation to intensive care (26% vs 21%).

Decisions in respect of ward level care were also affected. In the absence of a DNACPR decision, clinicians were more active in providing naloxone for a potential opioid toxicity (57% vs 29%).

Conclusion

Patients’ concern that a DNACPR decision might reduce the intensity of care they might receive do not appear to be unfounded. We believe that this study demonstrates the reality of clinical decision making in acute patient care.

These clinicians will have been aware that DNACPR status should have no influence on other clinical decision making, but unconscious bias clearly has substantial influence despite this. We do not believe that training to reinforce such knowledge will ever fully compensate for such unconscious bias.

Clinicians need to consider how DNACPR decisions are made, recorded and communicated given this risk of unforeseen consequences for other aspects of care.

Introduction: At Warrington hospital, a small district general, the orthogeriatric team adheres to national guidelines by conducting bone health assessments for inpatients with neck-of- femur (NOF) fractures and commencing suitable secondary prevention measures. However, there is a noticeable gap in secondary prevention for patients with non-NOF fractures requiring admission (such as tibial or humeral fractures). This predisposes patients to a future increased risk of disability, morbidity and mortality following discharge.

Method: A Quality Improvement initiative was launched, introducing various interventions such as educational sessions for doctors and pharmacists, E-learning modules and a flow chart poster guiding bone health assessment. Bone health teaching and all interventions were shared and at each doctors changeover inductions, to reinforce and sustain change.

Results: Preliminary data in January 2023 identified that 0% of patients with non-NOF fractures received secondary prevention and only 7% had bone health mentioned in the discharge summary. The results of teaching alone from May 2023, indicated improved clinician knowledge and confidence, but only modest clinical improvement. However, by December 2023, the combined interventions demonstrated significant progress; 92% of patients had bone health bloods performed, 57% of patients were identified as requiring treatment and 70% of those received appropriate management. Additionally, 82% of patients had bone health mentioned on their discharge summary.

Conclusion: The interventions enhanced the identification of patients requiring further investigation and management, underscoring the importance of a multimodal approach for tangible change. To further solidify these improvements, a checklist was created for medically fit patients and is utilised by the ward manager to guide the daily multidisciplinary board round. Furthermore, an order set within our ICE system was created to streamline requesting bone health blood tests. Whilst the outcomes of these interventions are outstanding and to be collected in May 2024, we anticipate greater improvements in outcomes.

Introduction

Geriatric medicine is inherently complex and requires multi-disciplinary integration. Simulation-based training has been recognised by the Joint Royal Colleges of Physicians’ Training Board and the Royal College of Nursing as a method to enhance learning and improve patient outcomes. This project aimed to develop a multi-professional simulation programme within care of the elderly to mimic the multi-professional clinical practice that takes place on geriatric hospital wards.

Methods

A total of ten half-day simulation sessions have been run across two sites in two years. The scenarios cover frailty, orthogeriatric post-operative complications, acute delirium, Parkinson’s disease, thrombolysis and end of life care. The sessions were attended by 57 participants, including 24 doctors, 20 nurses, 7 nursing students, 4 healthcare assistants and 2 physician associates. Quantitative and qualitative questionnaires conducted pre- and post- simulation were used to assess confidence levels and attitudes towards simulation as a learning tool.

Results

Both pre- and post- simulation, candidates had the most confidence in managing end of life situations, and least confidence in managing acutely unwell patients with Parkinson’s disease. Confidence levels for managing common geriatric scenarios increased by an average of 21% after candidates participated in the simulation session. Thematic analysis highlighted the importance of collaboration within a team to enhance a sense of belonging, and pro-activeness of staff to highlight deteriorating patients to colleagues and family members.

Conclusions

Simulation that mimics the ward environment is an effective tool in increasing the confidence of the multi-disciplinary team looking after geriatric patients through exposing candidates to complex situations and increasing awareness of the roles within the team. The simulation sessions have highlighted clinical areas that require further education within the Trust, such as thrombolysis. Future development of the simulation will aim to adapt the scenarios for use of the wider multidisciplinary team, incorporating therapists and pharmacists.

Introduction

The number of older adults accessing the healthcare service far exceeds the available geriatric specialist services. It is recognised that for the foreseeable future most hospital inpatient contacts with older adults will be completed by doctors not specifically trained in Geriatric Medicine. To ensure the provision of adequate healthcare, it is imperative that all hospital doctors are trained in the minimum Geriatric Medicine competencies. Allowing for the broad, complex, and multidisciplinary nature of Geriatric Medicine, we conducted a group concept mapping (GCM) study to permit multiple stakeholders with various expertise to convey their thoughts on the competencies required by all hospital doctors caring for older adults.

Methods

GCM is a mixed methods approach utilising six phases to generate expert group consensus, enabling participants to organise and represent their ideas. We invited healthcare professionals, patient advocacy groups and clinical educators to participate in GCM via an online platform. Hierarchical cluster analysis and multi-dimensional scaling were utilised to analyse participant input regarding competencies required by doctors caring for older adults.

Results

Twelve competency domains were identified by participants as integral for all hospital doctors to care for older adults. Domains rated most important related to interpersonal communication skills, medicolegal concerns, recognition and management of delirium and medication management.

Discussion

The twelve competency domains indicate the diverse skillset required by all doctors to provide comprehensive care to older adults within a hospital setting. The emergence of interpersonal communication skills underscores the importance of effective- doctor patient and interprofessional communication. Furthermore, the emphasis on medicolegal issues highlights the potential complex ethical and legal aspects in treating older adults. Recognition of delirium and medication management underline the specific challenges associated with caring for this specific population.

Conclusion

This study identifies competencies that may serve as a foundational framework for ensuring quality healthcare for the ageing population. Future initiatives should consider incorporating these competencies to improve inpatient care provided by hospital doctors to older adults.

Introduction

Falls are a common cause of morbidity and mortality in frail patients, with visual impairment doubling the risk of falls. NICE advises a multifactorial approach to identify risk factors to be treated, improved and managed. This includes sensory/visual assessment, which is poorly done in practice. The aim is for 50% of relevant patients admitted with fractures following falls to have a vision assessment within 5 days of admission.

Methods

A modified RCP ‘Look out! Bedside vision check for falls prevention’ aid for healthcare professionals was utilised. Patients excluded were those with significant delirium/dementia or medically unwell. We regularly collected data on how many patients had a vision assessment performed whilst implementing interventions such as Teaching Sessions, Posters and including visual assessments in the Comprehensive Geriatric Assessment(CGA).

Results

Initial results demonstrated poor rate of visual assessments in patients. With implementation of the modified tool, rates of visual assessments improved from 11%(n=1) to an average of 22%(n=4). Further interventions increased the overall average to 80%(n=36). The most effective intervention was including a visual assessment checkbox in the CGA. This improved rates of visual assessment in a subgroup of patients considered to have had falls due to visual impairment, from 33% to consistent rates of 100%. Additionally, the average days to assessment greatly reduced from 10.2 days to consistently under 5 days.

Conclusion

Identification of visual impairment reduces recurrent falls and hospital admissions. The project demonstrated the clinical significance of vision assessments - aiding the diagnosis of PSP, prescribing eye drops, and optician follow-up. Utilisation of the modified ‘Look Out’ tool is a simple way to assess vision on the ward. Posters and teaching sessions improved clinicians’ confidence. However implementing sensory impairment in the CGA proforma proved the most sustainable effort. Next steps include implementation in other Geriatric wards and Falls clinics.

Background: Studies show that newly qualified doctors feel unprepared for clinical practice in several key areas in the care of older people, despite older people occupying two thirds of inpatient beds [1,2]. Grounded in experiential learning theory, simulation has been hugely effective in undergraduate education in geriatric medicine [3]. We aimed to evaluate a novel simulation series exploring practically challenging aspects of geriatric medicine, such as ‘silver trauma’ and using de-escalation strategies in the management of delirium. Methods: Using quality improvement methodology, we developed two inpatient simulation scenarios for fourth-year medical students on their geriatric medicine clerkships. The scenarios (managing delirium and post-falls assessment) are commonly encountered during on-call shifts, with learning outcomes aligned to Outcomes for Graduates. Our initial cycle involved eight students piloting the two scenarios and evaluation tool. Using their feedback, we will iteratively improve the methods and evaluation before repeating and obtaining pre- and post-simulation data on students’ ‘preparedness for F1’. Results: Following the pilot, 100% of participants agreed that they felt more prepared for clinical work in geriatrics as an F1 doctor. 12.5% felt confident assessing a patient following a fall pre-session, which increased to 100% afterwards. Confidence in using de-escalation techniques in managing delirium improved from 50% (pre-) to 100% (post-session). Common themes in free-text feedback were that the simulation felt realistic and effectively tested prioritisation. Conclusion: Our work highlights the merits of using simulation in geriatric medicine to help undergraduates prepare for the complexities and uncertainty involved in caring for the ageing population.

References 1. Monrouxe LV, Grundy L, Mann M et al. BMJ Open. 2017;7(1). 2. British Geriatrics Society. Protecting the rights of older people to Health and Social Care [Internet] 2023. 3. Fisher JM, Walker RW. Age and Ageing. 2013 Dec 18;43(3):424–8.

Background:

Delirium is a common condition in hospitals, especially among older people. This refers to a dramatic decline in mental capabilities marked by diminished concentration and consciousness.

Aims:

The purpose of this study is to assess the views, knowledge, and behavior of non-consultant hospital doctors about managing delirium in a large Irish hospital. Methods: Questionnaires were given to 28 healthcare professionals from various departments according to Davis and MacLullicin (2009). It was conducted between July and September 2023 with emphasis on finding out its prevalence rate, diagnostic criteria, and management strategies for delirium.

Results:

The study established that majority of the respondents recognized the importance of delirium but there appears to be a gap in practical management of this clinical syndrome. Although many doctors agreed that delirium was significant, most lacked confidence in diagnosing as well as managing it. The use of standardized assessment tools like the 4AT was limited.

Conclusions:

This study highlights the disparity between what is known and practiced by hospital doctors concerning delirium care. It implies increased training for delirium management with frequent use of assessment tools and ongoing education aimed at enhancing patients’ outcomes during cases of delirium. Keywords:Delirium Management, Hospital Doctors, Medical Training, 4AT, Clinical Practice, Elderly Care.

Introduction: Many countries are facing an ageing population, and this is also evident in Singapore. To alleviate this matter and to cope with the increasing number of older persons today, nursing homes are also expanding. Residents of nursing homes are often frail and are at higher risk of multiple hospital admissions. On many occasions, the benefit of conveying the frail residents to acute hospitals is unclear and may even cause more harm. We implemented an acute hospital-nursing home collaborative pilot in two nursing homes with an objective to reduce emergency department visit and inpatient hospitalization among nursing home residents. We aim to study the experiences of healthcare personnel who were involved in an acute hospital-nursing homes collaboration in managing acutely ill residents.

Methods: Explorative qualitative interviews were conducted with fifteen nursing staff from two nursing homes involved in the pilot collaboration. The interview transcripts were thematically analyzed.

Results: The study delved into five key thematic areas: knowledge and understanding, service satisfaction, challenges, enablers, and service improvements. It revealed that a significant portion of staff lacked a comprehensive understanding of the collaboration's objectives. Nevertheless, there was a consensus that they found reassurance in the accessibility of hospital providers without immediate activation of emergency services. Nursing home staff acknowledged enhancing their ability to identify residents requiring escalated care through this collaboration. The interventions utilized, such as the NEWS assessment tool, hospital transfer forms, and teleconsultation portal, were noted for their user-friendliness. Challenges encountered included pressure from next-of-kin favouring treatments in acute hospitals over nursing homes and insufficient on-site resources. Identified enablers included a robust support system and the competency and motivation of nursing home staff to enhance residents' care, facilitating collaboration. Recommendations for improvement highlighted the need for training and skill development among nursing staff and workforce enhancement to bolster collaboration adherence.

Conclusion: These key themes highlight the significance of the collaboration between nursing homes and hospitals in improving care for residents, while also acknowledging the challenges and areas for future improvements.

Introduction:

BGS reports in its 'Case for more Geriatricians' that the number of people age over 85 is set to double by 2045. As well as Geriatric specific policies in the Ageing Well programme of the NHS Longterm Workforce Plan there are plans to expand the number of allied health professionals including Physician Associates (PA). We set out to improve PA students knowledge of and confidence in managing geriatric patients with a bespoke teaching programme culminating in a novel bleep simulation.

Methods:

We identified the students needs with a preliminary survey and then created a teaching programme on medical topics and issues common to geriatric wards with weekly lectures and small group work. The programme culminated in a bleep simulation where students were contacted via bleep to come to different parts of the medical education centre and respond to scenarios which would be common on geriatric wards. These included reviewing unwell patients and issues such as aspiration, constipation and urinary retention. The students were required to amend or create prescriptions and interpret test results with access to the BNF and relevant local guidelines.

Results:

Students were asked how useful the simulation was and how much it had improved their confidence in working on geriatric wards. The average score for both statements was greater than 9/10. The students were asked before and after the simulation how confident they were responding to bleeps and managing clinical scenarios in geriatric patients. Both scores doubled following the simulation to 6.7/10 (from 2.5 and 3.3 respectively).

Conclusion:

The Faculty of Physician Associates curriculum does not necessitate placements in geriatrics and its matrix of core clinical conditions does not include any specific to geriatrics. Through a bespoke teaching programme and a novel bleep simulation we increased PA students confidence in managing geriatric patients.