Joints

Introduction: Femoral fragility fractures (FFFs) are a significant healthcare concern, with the incidence predicted to rise to 100,000 annually in the UK by 2033. Current secondary preventative strategies focus on the patient’s physical state – overlooking Hospital-associated Deconditioning (HAD), the decline in patient wellbeing post-admission. To prevent HAD, a ‘Games Area’ (GA) was introduced in December 2023 as a service improvement. This study evaluates the GA’s effectiveness in preventing HAD, by assessing patient satisfaction.

Method: We evaluated all patients aged 65yrs or more during their post-operative rehabilitation for their FFF who were deemed fully weight-bearing and medically ready for discharge. The control group received the standard care provided by the ward’s multidisciplinary team, while the GA group also had access to the GA, where patients were encouraged to participate in activities with fellow inpatients. Activities included colouring, jigsaw puzzles and wordsearches. Data were collected via weekly questionnaires and medical records.

Results: Overall, 75 patients participated (38 in the control group, and 37 in the GA group). Patients in the GA group reported higher satisfaction ratings, with a mean score of 3.01 (SD = 0.406) out of 5, while the control group’s mean was 1.83 (SD = 0.279).

Conclusion: The GA acts as a simple, cost-effective intervention that can mitigate HAD by enriching the ward environment – hence, enhancing patient experience, and may improve patients’ physical, mental, and emotional health.

Hip fractures are a major public health issue due to ageing populations and Ireland has one of the highest hip fracture rates in Europe1. The cost of acute hip fracture care was 48.5 million euros in 20221. The Irish Hip Fracture Database in 2022 revealed that 84% of people presenting to acute hospitals with hip fracture were admitted from home, however only 29% were discharged directly home1. NICE guidelines recommend early supported discharge for patients who are medically stable and mentally fit to participate with rehabilitation and who can transfer and mobilise short distance but have not yet achieved their full potential2. The National Integrated Care Programme for Older Persons (NICPOP) improves the life of older people by providing access to integrated care and support that is planned around their needs and choices, supporting them to live well in their own homes3. This poster outlines the rehabilitation pathway established by the SJH ICPOP team to provide early supported discharge for hip fracture patients.

Introduction: On behalf of National Falls Prevention Coordination Group, we were tasked with creating a user friendly guide on Medicines and Falls. We delivered two sessions on this topic one at British Geriatric Society Conference in November 2023 and another to Specialist Pharmacy Service audience in January 2024.

Method: Audience participation was used in both sessions as part of the discussion on “What do you consider important when completing a medication review in a person who is at risk of falls?” and “Which group of medicines do you prioritise for deprescribing discussion in patients at risk of falls?”. The results from slido contribution were analysed for trends and future learning needs.

Results: In the SPS audience, greater level of importance was imparted on individual drug classes when considering question of “what is important when reviewing a person at risk of falls” with anticholinergic burden being quoted most frequently and patient goals being second. Reducing risk and patient goals were the two items which the BGS audience prioritised. In terms of groups of medication to prioritise for deprescribing discussion, SPS audience once again chose anticholinergic medication followed by sedatives while BGS categorised antihypertensives and diuretics most commonly.

Conclusion(s): When completing falls medication reviews, medication groups were most commonly thought as important by pharmacy-focused audience, with patient goals the second most important aspect whilst the BGS audience prioritised reducing risk and patient goals. There should be greater emphasis on managing risk as part of teaching offerings to teams where therapeutics is the core focus. In terms of groups of medications to deprescribe, better guidance around reviewing antihypertensives and diuretics would facilitate more effective falls medication reviews. The difference observed between prioritising anticholinergic burden reduction indicates that general geriatric audience would benefit from further awareness raising of their contribution to falls risk.

Introduction: The World Falls Guideline 2022 recommends that measurement of lying-standing blood pressure (LSBP) is an integral part of the multifactorial falls risk assessment (1). Pre-intervention less than half of eligible patients had a LSBP recorded and documented. The aim was to improve the recording and documentation of LSBP for adults aged 65 and over admitted with a fall or at high risk for falls. Method: All patients aged 65 and over admitted with a fall or identified as at high risk for falls to a care of the elderly ward were included over the period of 15th September 2023-15th November 2023. Royal College of Physicians (RCP) guidance (2017) for standard measurement of LSBP was used (2). Data was collected on electronic spreadsheets from electronic observation charts. Two plan-do-study-act (PDSA) cycles were conducted. Firstly, ward posters demonstrated how to record and document LSBP. Secondly, ward-based one-to-one teaching interventions using RCP LSBP lanyard flashcards (2) were conducted. Results: Following cycle one, 50% of eligible patients had LSBP documented. Following cycle two, 80% of eligible patients had LSBP documented. Following two PDSA cycles, there was a 37.1% increase in the average number of eligible patients who had LSBP correctly recorded and documented. Conclusion(s): Interventions of aide memoirs and education for nursing and medical staff improved the recording and documentation of LSBP. Indications and correct measurement guidance for LSBP should be included in future ward staff induction information and departmental teaching sessions.

1) Montero-Odasso, M, Van der Velde N, Martin FC et al. The Task Force on Global Guidelines for Falls in Older Adults , World guidelines for falls prevention and management for older adults: a global initiative, Age and Ageing, Volume 51, Issue 9, September 2022. 2) Measurement of lying and standing blood pressure: A brief guide for clinical staff. 2017. https://www.rcplondon.ac.uk/projects/outputs/measurement-lying-and-stan… 

Introduction:

Parkinson’s disease (PD) patients with or without psychosis are at higher risk of recurrent falls and fracture and as a consequence higher mortality and morbidity NICE (13) Henderson et al. (2019). We conducted a qualitative study to understand barriers and facilitators of introducing ‘bone health assessment’ for PD patients.

Method

We conducted a pilot study to identify and implement a bone health assessment tool to communicate falls and fracture risks to GPs. • SWOT and Stakeholder analysis was conducted to identify an appropriate bone health assessment tool . • PDSA cycles were completed to assess barriers and facilitators of bone health assessment in all PD clinical areas. • 4 Participants were identified from all possible PD clinical settings and trained on how to use the FRAX assessment tool. • Semi structured interviews were conducted to explore themes from 6 week pilot study.

Results

Bone health assessments were not conducted routinely in PD clinical settings in our Trust Literature review/ SWOT and Stake holder analysis identified ‘FRAX’ score as an appropriate bone health assessment tool for PD patients. Interviews with participants identified time constraints during the clinical consultation as a major barrier to conducting bone health assessment using the FRAX assessment tool. All participants agreed that this improved communication with patients and GPs in understanding bone health and risk of falls and fractures. Face to face PD Nurse Clinics were deemed the most appropriate clinical settings for these assessments.

Conclusion

As a result of this service improvement project bone health is now assessed in all PD Nurse clinics. This has enabled GPs to start the most appropriate bone protection treatment for PD patients

Introduction: Falls account for one of the most common and serious issues contributing to a disability, especially among elderly individuals. (1) Injuries resulting from a fall range from mild to severe, but they are all usually painful. (2) According to RCEM ‘Recognition and alleviation of pain should be a priority when treating the ill and injured’. (3) The aim of this project was to improve pain management in patients with falls being referred to the OPAL team. Studies have shown that patients whose primary pain is well managed and treated in the ED have a higher overall satisfaction with hospital services. (4)

Method: Two PDSA cycles have been completed. Initial data was collected retrospectively from 3/9/23 to 9/9/23 to gather baseline information on current practice. Data was collected from hospital patient’s electronic records. This was followed by teaching sessions and poster distribution to improve staff education highlighting ways to address pain and its management. Post intervention data was collected from 11/12/23 -17/12/23. Duplicate records and non-fallers were excluded.

Result: Initial data was collected on total 75 patients which showed nearly 50% of the patients were in pain when referred to OPAL team. Amongst the patients in pain, OPAL team advised for pain relief in only 1/3rd of them. Following intervention, data was collected on 57 patients following exclusion. It showed only 26.3% of the patients were in pain at the time of referral, a significant improvement from nearly half in the previous cycle. Also, OPAL team advised regarding pain relief in almost all patients in pain. As a result, 79% of the patient were pain free during OPAL assessment.

Conclusion: The QIP showed importance of staff education in improving pain management in elderly patients presenting with falls. Further PDSA cycles are planned to sustain the current improvement in practice.

Reference: (1) https://www.ncbi.nlm.nih.gov/books/NBK560761/

(2) https://www.ditomasolaw.com/blog/slip-and-fall-accident-should-be-sore/

(3) RCEM_BPC_Management_of_Pain_in_Adults_300621.pdf

(4) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6548151/

Introduction:

One of the key action areas of the World Health Organization third Global Patient Safety Challenge¹ ‘Medication Without Harm’ (WHO, 2017) is to reduce severe avoidable medication-related harm and address polypharmacy. NICE guidance on falls risk assessment and prevention² also includes medication review as part of its recommended multifactorial risk assessment (NICE, 2013). Use of Falls Risk Increasing Drugs³ (FRIDs) along with polypharmacy and anticholinergic burden are known to increase the risk of falls, particularly in older people². In 2021, Belfast HSC Trust appointed a pharmacist to work with the community falls multidisciplinary team and optimise medicines in older people at risk of falls, and we aim to explore the impact of this role on medicines optimisation in older people.

Method:

This research quantitatively evaluates the impact of the intervention of a novel community falls pharmacist role on medicines optimisation, in relation to FRIDs in older people who have had a fall. We will present data on admission and discharge from the service in relation to:

• Number and type of FRIDs prescribed
• Calculation of Anticholinergic Burden score using the ACBcalc® (King and Rabino, 2022)
• Polypharmacy- number of medications prescribed
• The appropriateness of medicines prescribed
• Undertake measurement of lying/ standing manual blood pressure to identify potential postural drop in blood pressure, and hypertension.
• Undertake a Bone health review using an approved tool (FRAX)
• Outcome of pharmacist referral of appropriate patients for DEXA scan using a new direct referral system
• Measure the significance of clinical interventions (Eadon graded)
• Calculate the cost avoidance of pharmacist interventions (ScHARR Tool) Results

Results:

92 patients were reviewed by phone (35%) or during home visit (65%), by the community falls pharmacist June 2022- August 2023.

• FRIDs³ prescribed, were identified and reviewed, and Anticholinergic Burden score (ACB) was measured using the anticholinergic burden calculator⁴ (ACBcalc®)
• The number of medications prescribed and the appropriateness of these was measured using Medicines Appropriateness Index⁵ (MAI)
• Significance of clinical interventions by the community falls pharmacist was measured using Eadon⁶ scale and cost avoidance of these measured using an adapted version of the ScHARR tool⁷. Potential cost savings⁸ from deprescribing, and  environmental impact were calculated (every £1 spent on pharmaceuticals generates greenhouse gas emissions 0.1558kg C0₂⁹)
• Lying/ standing manual BP measurement was undertaken
• Bone health review was undertaken using a fracture risk assessment tool¹⁰ (FRAX^®) & appropriate patients referred for a DEXA scan, using a new direct pharmacist referral pathway

Results indicate a medicines review by the community falls pharmacist leads to a statistically significant reduction in polypharmacy (¯8%; p<0.05) and ACB (¯33%; p<0.05), an increased appropriateness of prescribing (MAI ¯56%; p<0.05), 317 clinically significant interventions, identification of blood pressure issues (22%) eg orthostatic hypotension, and identification of osteopenia (n=14) or osteoporosis (n=3) using a new pharmacist DEXA referral pathway. Amitriptyline was the most common FRID deprescribed (22%). Annual cost avoidance due to pharmacist interventions were in the range of £28160 – £62358 along with drug cost savings of £6041, amounting to total savings of £34201-£68400, and invest to save return of one to two pounds for every £1 invested. Benefit to the environment of reduced inappropriate prescribing amounted to almost 1 tonne of avoidable CO₂ emissions per year.

Discussion:

The pharmacist review had a statistically significant impact on reducing the ACB score by an average of 33% . The MAI pre- and post-review reduced  by an average of 56% indicating an improvement in appropriateness of prescribing.  101 FRIDs were deprescribed & amitriptyline was deprescribed in 22% patients. 94% of clinical interventions were significant resulting in improvement in care and an additional 19 preventing potentially serious outcomes.

Conclusion:

Introduction of a community falls pharmacist role is an effective and cost efficient means to optimise medicines in older people who experience falls, as well as having a positive impact on the environment. The community falls pharmacist ­ prescribing appropriateness, generates a return of £1-£2 per £1 invested, & ¯CO₂ emissions by 1 tonne

1 World Health Organisation (WHO) Third Global Patient Safety Challenge: Medication Without Harm 2017 www.who.int

2 NICE Falls In Older People: Assessing risk and prevention Guidance 2013 www.nice.org.uk

3 Falls Risk Increasing Drugs (FRIDs): NI Medicines Optimisation Older People (MOOP) 2022

4 ACBcalc® ACB Calculator web app created by Dr Rebecca King and Steve Rabino

5 Hanlon, J. et al. A method for assessing drug therapy appropriateness, J Clin Epidemiol. 1992 45(10):1045-51

6 Eadon, H. Assessing the quality of ward pharmacists’ interventions. Int J Pharm Pract. 1992 1:3; 145-147

7 Miller, R. et al. Consultant pharmacist case management of older people in intermediate care. EJPCH 2016 4:1; 46-52

8 Health & Personal Social Services NI September 2023 Drug Tariff (hscni.net)

9 Gompertz, D. ‘Show me your meds, please’: the impact of home-based medicines assessments. The Pharmaceutical Journal 2023 vol 310. no. 7971;310

10 Fracture Risk Assessment Tool (FRAX®) University of Sheffield www.frax.shef.ac.uk

Introduction

Over 500,000 fragility fractures occur in the UK each year (1). NICE guidelines state that all women aged ≥65 and all men aged ≥75 should be considered for a fracture risk assessment. It was recognised that locally these guidelines were not being met. The aim of this quality improvement project was to improve the number of patients being assessed for osteoporosis across two medical wards.

Method

This quality improvement project followed two “Plan Do Study Act” (PDSA) cycles. The first cycle involved teaching sessions for junior doctors on using the FRAX tool – a tool recommended by NICE guidelines to estimate 10-year predicted absolute fracture risk. Posters and visual reminders were placed around the wards. The second cycle involved creating a sticker which was placed in patients’ medical records prompting doctors to calculate FRAX scores and document the results. Patients deemed inappropriate for bone protection and patients already receiving bone protection prior to admission were excluded.

Results

A baseline set of data showed that 0% of patients had undergone fracture risk assessment, therefore resulting in no patients being prescribed bone protection or being referred to osteoporosis clinic. Repeat assessment after the first intervention showed 29.7% of patients had undergone fracture risk assessment, 13.5% were prescribed bone protection and 16.2% referred to osteoporosis clinic. After the second intervention, 80% of patients had undergone fracture risk assessment, 10% were prescribed bone protection and 55% referred to osteoporosis clinic.

Conclusion

Use of the FRAX tool was moderately increased by the targeted training of junior doctors and markedly increased by using a visual memorandum in the patient records. This led to an increase in treatment for osteoporosis, reducing patients’ future risk of fragility fractures.

References

1. National Osteoporosis Society. Susan's story: Osteoporosis 2017. https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2017/02/rightcare-susans-story-full-narrative.pdf

Introduction

Physical and cognitive frailty combined with unfamiliar surroundings in hospitals puts elderly patients at high risk of falls. It has been demonstrated that patient-centred, non-clinical stimulating activities in hospital have been found to reduce agitation, improve affect and engagement, relieve pressure on nursing staff and reduce falls. In the Medicine of the Elderly (MOE) wards of an urban teaching hospital, after a successful pilot, a Meaningful Activity Team (MAT) was implemented. The effect of this change to patient and staff well-being was assessed, as was the frequency of falls on the wards.

Methods

The MAT was implemented by July 2023. In November 2023, questionnaires were distributed to staff across the MOE department to collect quantitative (Likert scales) and qualitative data on potential benefits and limitations. As part of our Quality Programme, prevalence of patients admitted to MOE wards with a diagnosis of dementia/delirium is regularly measured, as are patient falls, which are recorded via DATIX and collated on ward-based run charts. We interrogated these charts for any significant changes.

Results

The current prevalence of patients with delirium/dementia across the MOE 152 bed footprint is 69%. 49 staff questionnaires were completed, 47 of which had comments. 100% of respondents agreed or strongly agreed that the MAT benefited patient well-being. 87.8% agreed or strongly agreed that the MAT benefited staff well-being (figures 1, 2). Common themes regarding patient well-being were patients being happier, brighter and more sociable. Common themes regarding staff well-being included less stress and increased time for clinical tasks. The frequency of falls has reduced with some wards seeing maintained shifts in median number.

Conclusion

Implementation of the MAT across our MOE wards has improved patient and staff well-being. Reductions noted in frequency of falls have been maintained.

Background

Fragility fractures, defined as fractures resulting from low energy trauma (1), are consistent with a diagnosis of osteoporosis. When a patient is discharged from hospital, guidelines recommend principal and additional diagnoses, relevant co-morbidities contributing to primary diagnosis, medications and relevant investigations are recorded (2).

Methods

This audit reviewed discharge summaries of all patients discharged from a rehabilitation unit over two months, in accordance with the Health Information and Quality Authority’s (HIQA) National Standard for Patient Discharge Summary Information (2). Patients with fragility fractures were identified through medical record review. Principal and additional diagnoses were reviewed, with cause and mechanism of falls considered relevant co-morbidities. Discharge prescriptions for anti-resorptive medications were noted. Dual-energy x-ray absorptiometry (DXA) was recorded as a relevant investigation (3).

Results

33 discharge summaries met inclusion criteria. 12 patients were admitted with fragility fractures with a mean age of 81 years (69-90). 83.3% (n=10) were female. Osteoporosis was mentioned in 50% (n=6) of discharge summaries of patients with fragility fractures. On review of relevant co-morbidities, likely cause of the fall was documented in 58.3% (n=7) and mechanism in 75.0% (n=9). Bone protection was planned in 83.3% (n=10). Plan for DXA was documented in 8.3% (n=1)

Conclusion

This audit demonstrates suboptimal communication between hospital and community teams, despite chronic disease being predominantly managed in the community. In Europe, Ireland has one of the largest disease burdens relating to osteoporosis and the largest increase predicted in the next ten years (4) . It is of utmost importance we improve communication to minimise disease burden.

References

1. International Osteoporosis Foundation (2023) Fragility Fractures. https://www.osteoporosis.foundation/health-professionals/fragility-frac… (Accessed on 30 August 2023).

2. Health Information and Quality Authority (2013) ‘National Standard for Patient Discharge Summary Information’. Dublin: Health Information and Quality Authority. https://www.hiqa.ie/reports-and-publications/health-information/nationa…- patient-discharge-summary-information (Accessed on 30 August 2023).

3. Irish Osteoporosis Society (2023) About Osteoporosis. https://www.irishosteoporosis.ie/information-support/about- osteoporosis/#accordion-0-10 (Accessed 30 August 2023).

4.Carey, J.J., Erjiang, E., Wang, T., Yang, L., Dempsey, M., Brennan, A., Yu, M., Chan, W.P., Whelan, B., Silke, C., O'Sullivan, M., Rooney, B., McPartland, A. and O'Malley, G. (2023), Prevalence of Low Bone Mass and Osteoporosis in Ireland: the Dual-Energy X-Ray Absorptiometry (DXA) Health Informatics Prediction (HIP) Project. JBMR Plus, pp. 1-10.