Scientific Research

Background: The serious outcomes of outbreaks of COVID-19 in care homes have been described internationally. The experiences of professionals working through outbreaks has received less attention, missing opportunities to acknowledge and learn lessons. Our aim was to explore the experiences of care home staff in Scotland of managing COVID-19 within their homes to help inform understanding and future practice.

Methods: From April to August 2022, 34 individual semi-structured interviews were conducted with care home staff working in homes which experienced an outbreak(s) of COVID-19. Reflexive thematic methods were used to analyse verbatim deidentified transcripts.

Findings: There was no singular experience of COVID-19 outbreaks within care homes. We identified four broad groupings of homes with outbreaks (significant outbreaks, managed outbreaks, outbreaks in remote/rural homes & outbreaks in homes supporting younger adults), with overlaps in timing and severity and variation in the support received and impact. The national response to the COVID-19 pandemic resulted in fundamental change to care home relationships. Staff responded by adaptation in uncertainty. However, they were challenged by emerging inequalities influencing residents’ care. There were tensions between staff experience and evolving external approaches to regulation and oversight. All this change resulted in psychological impacts on staff. However, there was also widespread evidence of compassionate leadership and teamwork in their responses. Effective sources of support were underpinned by respectful relationships and continuity, tailored to individual contexts.

Conclusions: The lived experiences of care home staff during the COVID-19 pandemic provide valuable insights applicable beyond the pandemic context. This includes: recognition of the specialism, complexity and diversity of care home practice; the value afforded by embedding genuine representation and involvement in planning, policy-making and research; the need for individualising to people in their contexts and the value of fostering respectful relationships across professional groups to support residents.

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.

The objectives were to assess recruitment rate and feasibility of online survey delivery, and 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 and their role, with 5-point Likert scales of confidence.

Descriptive statistics and Chi-square analyses were used for quantitative data.

Results:

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

76% of respondents were paramedics, and 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 appeared to be significant variation between confidence levels relating to utilisation of hospital pathways and localities (p-value=.0045).

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

Conclusion:

The overarching confidence of clinicians did not significantly vary around the region.

Locality of work had a relationship with confidence in utilising hospital avoidance pathways, however, did not relate to confidence in assessing this patient population.

Confidence was not found to increase for either total years providing healthcare, nor providing emergency frontline care.

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

Introduction:

The use of pneumonia scores to stratify the prognosis is very useful in general terms, since it allows objectively evaluating the risks in these patients. The main objective was to determine the usefulness of pulse oximetry as a substitute for urea of the CURB 65 score in the evaluation of the severity of comunity acquired pneumonia (CAP) in patients.

Methods:

open-label, mixed-type study, first cross-sectional phase Test vs. Test, second phase follow-up at 8 and 30 days. Carried out between November 2017 and April 2018.

Results:

5 patients, gender distribution was comparable, the main age group was made up of over 65 years. The frequency of comorbidities was greater than 90%, among which hypertension, diabetes and smoking stand out. The mean hospitalization time was 10 days. The variable that most defined the need for hospital admission was hypoxemia with a percentage of 72%, regardless of the score on the CURB 65 scale, it was shown that oxygen saturation <92% is associated with a high 30-day mortality rate ( 43.07%) n=28, (p 0), with a relative risk of at least 4 times more to die. When correlating the CURB 65 and CORB 65 scales with Spearman's Rho test, a correlation coefficient (0.898) was obtained.

Conclusions:

pulse oximetry proved to be a good substitute for urea in the CURB 65 score, useful for defining hospitalization, severity, and mortality in patients with CAP.

Introduction

Postural BP readings are important in assessing older people, but are infrequently measured (1) The National Audit of Inpatient Falls (NAIF) 2022 has shown measurement of lying standing blood pressure (LSBP) remains below 50% (2)  

NICE guidelines suggest checking LSBP in patients with:  

1) Hypertension and postural hypotension symptoms  

2) Hypertension and Type 2 diabetes  

3) Hypertension and age ≥ 80 years (3)  

4) Patients presenting with falls (4).  

We aimed to update local data for LSBP recording and investigate LSBP measurements in hypertensive patients.

Method   

Data was collected across 4 wards in University Hospital of Wales between 22^nd May and 9^th June. Patient notes and NEWS charts were reviewed to establish whether an LSBP was necessary and carried out according to NICE guidelines (2) and whether appropriate reasons were documented.   

Results   

The table below shows the number of patients required and completed LSBPs.  

Total Number of Patients  98  

Number of Patients requiring a LSBP  76 

Total number of postural measurements completed 18 (16 LSBP, 2 sit/stand) 

Number of acceptable reasons for not completing postural BP reading  12 

All categories of patient requiring a LSBP have <40% completion; no LSBP’s were completed in patients that were hypertensive and diabetic.

 Conclusion  

Results indicate that local LSBP measurement requires improvement, with only 24% of requiring patients having a postural reading completed. Significant variations in guidelines (NAIF (2), MFRA (4), Cardiff and Vale Falls Policy (5)) have been highlighted as a potential factor, hence clearer guidance is needed on when LSBP is required, to improve detection of postural hypotension and therefore improve falls prevention and hypertension management.  

 References  

1. Detecting Risk of Postural hypotension. BMJ. 2020  
2. National Audit of Inpatient Falls report 2022.  
3. NICE. Hypertension in adults 2022  
4. NICE. Falls in older people 2013. 
5. CAVUHB. Falls Policy 2021  

Introduction

Falls in older people are common and can lead to significant harm including death. Coroners in England and Wales have a duty to report cases where action should be taken by organisations to prevent deaths, but dissemination of the findings from these Prevent Future Deaths (PFD) reports remains poor, limiting their possibility to effect change. We set out to identify preventable fall-related deaths, classify coroners’ concerns, and explore organisational responses to these deaths.

Methods

A protocol for a retrospective case series of fall-related PFDs was pre-registered. A novel, openly available, computer code was created to download and read PFDs from the Courts and Tribunals Judiciary website from July 2013 to November 2022. Demographic information, coroners’ concerns and responses from organisations were extracted. Descriptive statistics and content analysis were used to synthesise data.

Results

527 PFD cases (12.5% of all PFDs) involved a fall that contributed to death. These deaths predominantly affected older people (median 82 years) in the community (72%), with subsequent death in hospital (71%). A high proportion of cases experienced fractures, major bleeding, or head injury. Coroners frequently raised concerns regarding falls risks assessments, failures in communication, and documentation issues. Only 56.7% of PFDs received a response from the intended recipients. Organisations most commonly produced new protocols, improved training, and commenced audits in response to PFDs.

Conclusion(s)

One in eight preventable deaths reported in England and Wales involved a fall. Adequately addressing concerns raised by coroners should improve falls prevention and care following falls especially for older adults. Poor responses to coroners may indicate that actions are not being taken at the local level. Wider dissemination and learning from PFD findings may help reduce preventable fall-related deaths nationally.

Introduction: In the current European guidelines, sarcopenia is diagnosed on the basis of low muscle strength, with low muscle mass used to confirm diagnosis. The added value of measuring muscle mass is unclear. We performed a systematic review to assess whether muscle mass was independently associated with adverse outcomes in patients with hip fracture.

Method: The systematic review protocol was registered on the PROSPERO database (CRD42021274981). Electronic databases (MEDLINE, EMBASE, CENTRAL, CINAHL, Clinicaltrials.gov) were searched for observational studies of patients with hip fracture aged ≥60 who had muscle mass or strength assessment perioperatively. Two reviewers independently screened titles/abstracts for inclusion. The association of muscle mass or strength with postoperative outcomes (mortality, Barthel Index, mobility, physical performance measures, length of stay, complications) was recorded. Risk-of-bias was assessed using the AXIS or ROBINS-I tool as appropriate. Due to the degree of study heterogeneity, data were analysed by narrative synthesis.

Results: The search strategy identified 3,007 records. Ten studies were included (n=2281 participants), containing 27 associations between muscle mass assessment and hip fracture postoperative outcomes. Four studies had intermediate risk of bias; 6 studies had high risk of bias. Lower muscle mass was associated with higher mortality and worse physical performance measures in univariate analyses but there was no significant association between muscle mass and mobility, length of stay and postoperative complication scores in any included study. Six studies assessed both muscle mass and strength. Muscle mass was not a significant independent predictor of any adverse outcome in any included study after adjustment for muscle strength and other predictor variables.

Conclusion: Data on the clinical utility of muscle mass measurement in patients with hip fracture are limited in volume and quality, but available studies suggest muscle mass does not offer additional prognostic benefit to muscle strength measures.

Introduction

Sustaining independence is important for older people, but there is insufficient guidance about which community services to implement.

Methods

Systematic review and network meta-analysis (NMA; PROSPERO CRD42019162195) to synthesise effectiveness evidence from randomised or cluster-randomised controlled trials of community-based complex interventions to sustain independence for older people (mean age 65+) living at home, grouped according to their intervention components. Main outcomes: Living at home, activities of daily living (ADL), care-home placement, and service/economic outcomes at one year. We searched five databases and two registries, and scanned reference lists. A random-effects NMA was used. We assessed risk of bias, inconsistency, and certainty of evidence.

Results

We included 129 studies (74,946 participants). Nineteen intervention components, including ‘multifactorial-action’ (individualised care planning), were identified in 63 combinations. Few studies contributed to each comparison. High risk of bias and imprecision meant results were very low certainty (not reported) or low certainty (unless otherwise stated). Findings may not apply to all contexts. For living at home, evidence favoured ‘multifactorial-action and review with medication-review’ (odds ratio (OR) 1.22, 95% CI 0.93 to 1.59; moderate certainty), and three other interventions: ‘multifactorial-action with medication-review’; ‘cognitive training, medication-review, nutrition and exercise’; and, ‘ADL, nutrition and exercise’. Four interventions may reduce odds of remaining at home. For instrumental ADL (IADL), evidence favoured ‘multifactorial-action and review with medication-review’ (standardised mean difference (SMD) 0.11, 95% CI 0.00 to 0.21; moderate certainty). Two interventions may reduce IADL. For personal ADL, evidence favoured ‘exercise, multifactorial-action and review with medication-review and self-management’ (SMD 0.16, 95% CI -0.51 to 0.82). Among homecare recipients, evidence favoured addition of multifactorial-action and review with medication-review (SMD 0.60, 95% CI 0.32 to 0.88). Other findings were inconclusive.

Conclusions

The intervention combinations most likely to sustain independence include multifactorial-action, medication-review and ongoing review of patients. Unexpectedly, some combinations may reduce independence.

Exercise is beneficial for Parkinson’s disease (PD), but many people struggle to achieve the 150 minutes per a week recommendation. Symptoms of PD or co-morbidity may be barriers for exercise; and physiotherapists can provide expert assessment and tailoring of exercise to accommodate these needs. We developed a remote physiotherapy intervention using videoconference (Attend Anywhere). An ongoing feasibility trial is assessing this intervention, and a process evaluation seeks to understand the broader context and acceptability of the intervention. Here we present a qualitative study of participants of the feasibility study. We invited participants from the feasibility trial to individual semi-structured telephone or videoconference interview. 14 participants were interviewed. Transcripts were analysed by thematic analysis within two main themes: physical activity and use of digital technology. Participants spoke about their attitudes towards their diagnosis. Individuals who had come to terms with their PD were more engaged with the exercise regime than participants who expressed a sense of denial. Participants who mentioned the benefits of exercise for reducing or delaying PD symptoms were more likely to report a positive attitude to exercise. In contrast, individuals with co-morbidity, or caring roles, found it more difficult to commit to regular exercise; flexibility of the exercise routine was valued. For the theme of digital technology some participants reported struggling with, technical problems such as interruptions in internet connection, having constrained space to exercise and staying in view of the camera for the physiotherapist. Whilst some participants lacked digital confidence, or expressed a preference for in-person treatment, other participants reported no difficulties or found it more convenient than travelling to clinic.

Introduction

Over 250 medications are reported to cause postural hypotension, associated with serious adverse outcomes in older adults. Studies in the literature and guidelines suggest a harmful cumulative risk of postural hypotension with multiple medication use. However, there is limited evidence on the potential for harm in practice, particularly which drugs are co-prescribed and may increase risk of postural hypotension.

Methods

Retrospective cohort study and cluster analysis using general practice data from IQVIA Medical Research Data (IMRD) in patients aged ≥50 contributing data between 1 Jan 2018 and 31 Dec 2018. Thirteen drug groups known to be associated with postural hypotension by mechanism were analysed and clusters generated by sex and age-band.

Results

602,713 individuals aged ≥50 with 283,912 (47%) men and 318,801 (53%) women were included. The most prevalent prescriptions that might contribute to postural hypotension were angiotensin converting enzyme (ACE) inhibitors, calcium-channel blockers, beta-blockers, selective serotonin reuptake inhibitors and uroselective alpha-blockers. We identified distinct clusters of cardiovascular system (CVS) drugs in men and women at all ages. CVS plus psychoactive drug clusters were common in women at all ages, and in men aged ≤70. CVS plus uroselective alpha-blockers were identified in men aged ≥70.

Conclusion

Distinct clusters of drugs associated with postural hypotension are commonly prescribed in practice, which change over the life course in men and women. Our findings highlight potentially harmful drug combinations that may cause a cumulative risk of postural hypotension in older people. This may guide clinicians about the potential of synergistic harm and to monitor for postural hypotension if using such combinations – particularly in patients aged ≥70 or at high-risk due to comorbidity.

Introduction

• Delirium is common in hospitalized older patients. It is associated with increased mortality, poorer functional outcomes and increased length of stay.
• It has also been shown to be positively associated with level of co-morbidity in older postoperative patients.
• The aims of the study is to assess the correlation between delirium and co-morbidity in older medical inpatients. It also aim to determine the effect of gender on this association.

Method:

• This was a prospective, cross-sectional analysis carried out as part of a Quality Improvement Project on screening for delirium in older patients admitted acutely on medical wards from 6th to 12th October 2022.
• Patients were included if they were 65 years and over.
• Exclusion criteria were patients younger than 65 years. Patients with incomplete data were also excluded from analysis.
• Patients were screened for delirium using the 4-AT screening tool which is well validated.
• In addition the patients’ co-morbidities were assessed using the age-adjusted Charlson’s Comorbidity Index(CCI).
• The SPSS 29 IBM software was used for statistical analysis. Baseline characteristics were calculated using descriptive statistics. Pearson’s correlation co-efficient and linear regression analysis were used to calculate correlation.

Results:

• 233 patients in total were assessed - 119 males and 114 females.
• Median age was 79.4 years in males (Interquartile range – IQR – 11) and 83.5 years in females (interquartile range – IQR – 12).
• Overall mean age was 81.6 years (SD 8.1).
• The prevalence of likely delirium was 32.2 %.
• There was a statistically significant positive correlation between 4-AT and CCI  (r=0.236; p<0.001).
• This effect was stronger in male than female patients (r=0.275, p=0.002 vs r=0.197;p=0.035 ; respectively).

Conclusion:

• There was a statistically significant positive correlation between elevated 4AT score and CCI in acutely hospitalized older medical patients. This correlation was stronger in males.

  • The association needs more studies to validate these findings.