Cardiovascular

Introduction

Small vessel disease (SVD) lesions may cause symptoms apart from stroke. We aimed to determine whether white matter hyperintensity (WMH) progression and incident infarcts associate with gait, mood, and cognitive symptoms.

Method

We recruited patients with non-disabling stroke (modified Rankin Scale <3), performed diagnostic MRI, and questioned participants/informants about gait, mood, cognitive, Center Epidemiologic Studies-Depression Scale (CES-D), Neuropsychiatric Inventory-Questionnaire (NPI-Q) symptoms and Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE).

The baseline visit occurred < 3months post-stroke. We repeated MRI and symptoms assessments every 3-6 months for 12 months, assessing WMH change and incident infarcts (i.e. new since previous scan) on DWI or FLAIR. We analysed WMH using cubed root normalised for intracranial volume. We used linear mixed-effects models, adjusting for age, gait speed, modified Rankin Scale, and time for gait symptoms; age, anxiety, MoCA, stroke subtype, and time for cognitive/neuropsychiatric symptoms. 

Results

We recruited 230 participants (mean age=65.8 [SD=11.2] years; 34% female; 56.5% lacunar); median baseline WMH volumes = 8.26mL (IQR 3.65-19.0); one-year = 8.24mL (IQR = 4.15-20.1). Incident infarcts (n=110, 82/110 (74.5%) small subcortical subtype) occurred in 53/230 (23%) of patients.

WMH progression over one year was associated with falls (OR=4.13 [95% CI=1.6-10.1]); self-reported brain fog (OR=3.13 [95% CI=1.11-8.82]); and increasing NPI-Q scores (est=2.12 [95% CI=0.46-3.77] p=0.012). Baseline and one-year WMH volumes were cross-sectionally associated with apathy (baseline OR=8.78 [95% CI=2.56-31.88]; one-year OR=4.83 [95% CI=1.43-17.26]).

Higher CES-D depression scores were associated with incident infarcts (mean 15.2 [12.9] with vs 11.9 [SD10.6] without; est=2.26 (95% CI=0.12-4.4), p=0.038). WMH progression and infarcts were not associated with fatigue, anxiety, subjective memory complaints, confusion, dizziness, or IQCODE scores.

Conclusions

SVD progression following minor stroke co-associates with specific gait/cognitive/mood symptoms. WMH progression and incident infarcts may cause non-focal, non-stroke symptoms which characterise a potential ‘SVD syndrome’.

TITLE: Improving the Practice of Measuring Lying and Standing Blood Pressure Among Nursing Staff at a District General Hospital

INTRODUCTION: 

Postural hypotension is a significant cause of morbidity in the frail and older population, contributing to falls and related injuries. Accurate measurement of lying and standing blood pressure (LSBP) is essential for identifying patients at risk. This quality improvement project (QIP) aimed to address gaps in LSBP measurement practices among nursing staff by aligning them with Royal College of Physicians (RCP) guidelines. The project sought to raise awareness and improve the accuracy of these measurements, thereby enhancing patient care and safety.

METHODS:

Baseline data was collected from patient notes to assess the accuracy of documented LSBP readings. Additionally, a survey was conducted to evaluate nursing staff’s knowledge of postural hypotension and their interest in further education on the topic. In response, RCP posters detailing correct LSBP measurement techniques were displayed across the wards. Information about these resources was disseminated among the Geriatrics Department, including nurses, junior doctors, registrars, and consultants, and introduced during junior doctors' teaching sessions. To reinforce the practice, placards with measurement reminders were attached to all observation machines. Awareness sessions were concurrently conducted during PDSA cycles to ensure continuous staff engagement and understanding.

RESULTS:

Following two intervention cycles, there was a 50% increase in adherence to the standing BP measurement protocol. Pre-intervention, 66% of respondents were aware of the correct LSBP measurement process, which increased to 100% post-intervention. Additionally, 83% reported knowing where to access further resources on postural hypotension, compared to 44% pre-intervention levels.

CONCLUSION:

The sustained improvement in LSBP measurement compliance demonstrates the effectiveness of multi-faceted interventions, including education, visual prompts, and training. These efforts have facilitated a culture shift in patient management and are expected to improve patient outcomes.

The introduction of a standardised documentation proforma for LSBP measurement is anticipated to further support long-term improvements in this practice.

Introduction

Thomas Sydenham, English physician stated, “a man is as old as his arteries”. Chronological age has been noted to correlate strongly with vascular/ biological age. However, little is known about how chronological and vascular parameters of ageing, correlate with frailty. In this study, we sought to study the correlations between frailty, chronological age and parameters of vascular ageing.

Methods

Data from two studies with participants aged ≥ 60years investigating the associations between Cytomegalovirus infection and frailty indices and vascular parameters were included. Two hundred and sixty community dwelling adults were enrolled in both studies. Vascular parameters were measured by cardio-ankle vascular index (CAVI) using VaSera VS-2000® and pulse wave velocity-PWV (carotid-femoral and carotid-radial) using COMPLIOR®. Hand grip strength (HGS) and Charlson co-morbidity index (CCI) were measured for clinical frailty data. Patients were excluded if they had malignancy, were on active treatment for cancer or were unable to give consent.

Results

There were 260 study participants, (mean age ± SD; 72 ± 8years), with gender distribution M:F (50:50). Chronological age strongly correlated positively with vascular ageing parameters such as CAVI (r=0.6, p<0.001) and cf-PWV(r=0.5, p<0.01). Similarly, chronological age correlated positively with CCI (r=0.7, p˂0.001) and negatively with HGS (r= - 0.3, p˂0.001). Vascular ageing as measured by CAVI (estimated CAVI age) correlated positively with CCI (r=0.5, p<0.01) and negatively with HGS (r = -0.2, p=0.01). Other measures of vascular ageing such as cf-PWV positively correlated with CCI (r= 0.4, p<0.01) and negatively with HGS (r=- 0.1, p =0.09).

Conclusion

Clinical frailty parameters correlate strongly with measures of vascular ageing and chronological age. Vascular ageing is a strong independent predictor of frailty.

Background Royal Bolton Hospital is a district general hospital in Greater Manchester. In 2023, a Cardiogeriatrics service was introduced to deliver comprehensive geriatric assessment for older cardiology inpatients with frailty.

Introduction

Our aim was to evaluate the Cardiogeriatrics service with respect to the impact on end of life care for older cardiology inpatients.

Methods

Audit standards were defined using metrics for quality in end of life care. All patients between the year 2021 and 2024 aged 75 and over who died as an inpatient or within 30 days of discharge were included. Patients who died following procedural interventions were excluded. Patient’s casenotes were audited and compared before and after the initiation of the service.

Results

Casenotes for 88 inpatient deaths were audited (66 prior to introduction of the Cardiogeriatric service, 22 following). The Cardiogeriatrician initiated end of life care in 31.6% of inpatient deaths. This corresponded with a reduction in unexpected deaths from 26% to 14%, and a reduction in patients initiated on end of life care by the on-call team, from 31.8% to 10.5%. Junior doctors on Cardiology began to initiate resuscitation conversations with patients. Casenotes for 44 deaths within 30 days of discharge were audited, however no meaningful insight could be gained as there were only 6 outpatient deaths after the Cardiogeriatric service began.

Conclusion

After introduction of the Cardiogeriatrics service, there was improved recognition of patients who were approaching end of life, and more proactive management of this. As many patients audited were not seen directly by the Cardiogeriatrician, we believe the service has contributed to a cultural change in the Cardiology team more widely towards more proactive recognition and management of end of life issues in older Cardiology patients.

Introduction:

Heart failure (HF) is a pandemic syndrome characterized by raised morbidity and mortality. With the aging population, an acute heart failure event requiring hospitalization is associated with a poor prognosis and demands a longer hospital stay. However, the length of hospital stay and complication will increase if clinical and biochemical parameters are not observed, monitored, and corrected apart from mainstream medications (IV diuretics, ARNIs, BB, MRAs, and SGLT2i).

Objectives:

• Reduction of acute complications (such as AKI, electrolyte imbalance, etc.) related to heart failure medications (IV diuretics).
•  Shorten hospital stay.
• Less chance of developing hospital-acquired infections.
• Good quality of life.

Methodology:

A retrospective study of 45 patients was conducted through EPR notes in the Elderly and General Medical wards.  We conducted a 2-cycle study on patients with decompensated heart failure based on standard set parameters (Daily weight, targeted fluid balance, daily U&Es, intake-output charting) and looked for complications, length of hospital stay, and adherence to standard set parameters apart from mainstream treatment. Following the first cycle, awareness was raised through teaching sessions and poster presentations in targeted wards. All patients with decompensated heart failure who received IV diuretics were included in the study.

Results:

After interventions, we were able to demonstrate improved results compared to the initial cycle. Target fluid balance improved from 47% to 77%, daily weight from 17% to 43%, strict Intake-output charting 40% to 58%, daily U&Es 81% to 78%, and incidence of AKI 55% from 40%. Interestingly, the length of hospital stay was reduced by 2-3 days between two cycles.

Conclusion:

Strict adherence to clinical and biochemical parameters improved patient outcomes in terms of reducing complications and length of hospital stay in the management of decompensated heart failure. In this QIP we identified that this patient cohort was not adequately monitored. This was due to various barriers ranging from lack of awareness, staff pressures in the wards, and rapid turnover of the patients. Following a limited awareness campaign, we witnessed some improvement in some of the standards. There are, however, still areas of potential improvement. However, education alone is unlikely to address all of the barriers. Further cycles with other interventions such as making monitoring more efficient, streamlined, and electronic dashboards are likely to yield further improvement.

References:

https://www.nice.org.uk/guidance/cg187/resources/acute-heart-failure-diagnosis-and-management-pdf-35109817738693.

https://doi.org/10.1161/circheartfailure.108.821785.

https://cks.nice.org.uk/topics/heart-failure-chronic/prescribing-information/diuretics/

 https://www.rcplondon.ac.uk/file/7440/download.

The National Institute for Health and Care Excellence (NICE) guidelines for management of head injuries on anticoagulation were updated in 2023, to maximise detection of clinically important falls whilst minimising unnecessary scans. They recommend computed tomography (CT) imaging to be considered within 8 hours if clinically appropriate [NG232].[1] The Newcastle upon Tyne Hospitals NHS Foundation Trust (NUTH) current local inpatient falls protocol recommends that all patients who have fallen with suspected head injury, on anticoagulation but in the absence of neurological changes or other underlying risk factors, should undergo CT imaging. This quality improvement project reviewed outcomes in this patient subset, retrospectively analysing patient data during a four-month period.

Between April to August 2024, 550 inpatient adult non-contrast CT head scans were performed at the Freeman Hospital (NUTH). 172 (31.2%, median age 77) of these scans were performed following an inpatient fall. 73 (42.4%) of these scans were performed with active anticoagulation as the solitary indication; in these patients, none (0%) had haemorrhagic pathology and therefore no neurosurgical intervention was required. This data strongly supports a review to rationalise our inpatient fall guidelines to align with the updated NICE recommendations which emphasise clinical judgement and shared decision making. This change should result in a meaningful reduction in valuable CT scanning and reporting time, associated costs and radiation exposure, without compromising patient care and outcomes.

Introduction: Orthostatic Hypotension is a significant cause of falls leading to injury and morbidity in elderly population. In an online survey by Royal College of Physicians (RCP) 271 out of 316 clinicians routinely performed these measurements and there were significant variations in how lying and standing BP is performed. This could have adverse effects on detection rates and accuracy of the procedure resulting in misdiagnosis. As a result, RCP has released guidance on L/S BP2 measurements in view of standardising practice and improving accuracy. The purpose of this QIP is to improve how L/S BP is measured and documented, by introducing poster on wards and re-audit the improvement in the correct method of measuring L/S BP.

Methods: Ward staff are audited to find out whether LS BP is measured as per RCP guidelines. Afterwards a poster of RCP recommended method of measuring LS BP are placed on ward and given to participants. The procedure of L/S BP measurement is re-audited after the intervention to find out changes in performing L/S BP (as per RCP guidelines).

Results: • 20% staff were aware of RCP guidelines on L/S BP procedure (90% after intervention). • 0-15% staff had formal training on how to measure L/S BP. • Over three times improvement in the method of procedure (20% to 65% after intervention). • 25% staff were documenting symptoms (improved to 85% after intervention). • 10% of staff knew how to interpret a positive result, improved to 60% after intervention.

Conclusion: • Staff education improves L/S BP Procedure, documentation and interpretation, it also helped raise staff awareness of the RCP guidelines and how to access them.

Background and aims

Delirium carries an eightfold risk of future dementia. Small vessel disease (SVD), best seen on MRI, increases delirium risk, yet delirium is understudied in MRI research. We aimed to determine MRI feasibility, tolerability, image usability, and prevalence of acute and chronic SVD lesions in acute delirium.

Methods

This case-control feasibility study performed MRI (3D T1/T2-weighted, FLAIR, Susceptibility-weighted, and Diffusion-weighted imaging (DWI) on 20 medical inpatients >65 years: 10 with delirium ≥3 weeks and 10 without delirium, matched for vascular risk, Clinical Frailty Scale (CFS), and cognitive status. We excluded acute stroke, agitation necessitating sedation, assistance of >2 staff to mobilise, and MRI contraindications. We measured scan duration, tolerability, image usability, acute infarcts on DWI, and chronic SVD features. Six months later, we recorded CFS and cognitive diagnoses.

Results

Mean age was 83.5 years (delirium 78.7 vs non-delirium 88.4); 13/20 were female; 17/20 had premorbid cognitive decline/impairment or dementia. Acquisition took mean 26.8 minutes. MRI was well-tolerated in 16/20 (7/10 in delirium arm; 9/10 in non-delirium arm). 4/20 had early scan termination but 20/20 had clinically interpretable images. We detected DWI-hyperintense lesions in 3/10 (33.3%) with delirium (2/10 small subcortical and 1/10 cortical) and in 3/10 (33.3%) without delirium (2/10 small subcortical; 1/10 cortical). Mean SVD score was 2.4 in delirium vs 3.3 without.

Conclusions

MRI is feasible, usable, and tolerable in delirium, and we detected DWI hyperintense lesions in one third of patients overall. This study indicates acute vascular contributions, including SVD, to delirium, supporting the need for larger studies.

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.