Joints

Title: A quality improvement project on falls prevention in patients admitted under the surgical team.

Modifiable and non-modifiable factors contribute to falls in older people. Our aim was to examine prevalence of risk factors for falls in patients >65 admitted under the surgical team and prevent readmittance through signposting to falls clinic.

The first cycle of this QIP involved a review of all sets of charts for patients >65 (n=12) admitted under the surgical team with fall-related injuries between Dec 2022- April 2023.

Parameters examined included whether an electrocardiogram (ECG), CT Brain and Lying/ Standing blood pressure (LSBP) was performed, or polypharmacy (>5 medications) was evident. We then delivered a presentation to the surgical team and signposted to the local falls service.

The second cycle involved examining the same data for the month of August 2023.  The second intervention involved highlighting the project to the surgical ward manager and encouraging ECG/ LSBP assessment.

In Cycle one, 3/12 (25%) of patients represented with falls.  4/12 (33.3%) of patients had an ECG and 11/12. Only 1/12 (8.33%) had their LSBP checked.  8/12 (75%) patients demonstrated polypharmacy, with no evidence of medication optimisation.

In Cycle 2, 5 sets of notes were reviewed. 4/5 (80%) had an ECG and 5/5, and only 1/5 (20%) had their LSBP included. 3/5 patients (60%) demonstrated polypharmacy and one patient (20%) was referred to falls clinic.  

In Cycle 3, 7 patients were admitted with falls. 3/7 had an ECG, 2 of which showed arrythmia . 7/7 had a CT brain and 0/7 had LSBP performed. 5/7 demonstrated polypharmacy and one patient was referred to falls clinic. One patient was readmitted with falls under surgeons and was not referred to falls clinic.

This project identifies modifiable falls risk factors in patients admitted under the surgical team following falls, highlighting the need for specialist geriatric input. 

Title: An audit examining the post-fall management of inpatient falls resulting in neck of femur (NOF) fractures. 

Background:

Inpatient hip fractures are a significant cause of morbidity and mortality in older patients.  National audits have identified multiple delays in the care of these patients.

Aims

To analyse the pathway of patients sustaining an inpatient hip fracture at our trust 

Method:

We examined medical records of patients sustaining inpatient hip fractures from 2020-2021 to collect data on; transfer method from floor, time to medical and geriatrician review, documentation of suspicion of hip fracture, analgesia given, times from fall to X-ray and surgery. We used standards from the National Hip Fracture database, the National Audit of Inpatient Falls and Royal College of Emergency Medicine guidelines. 

Results: 

15 patients were included. None were transferred using flat-lifting equipment.

33% received a medical review within 30 minutes, in 47%, a hip fracture was not suspected. 53% were given a fascia-iliaca block, 33% were managed with paracetamol. 

Average time from fall to x-ray request was 14 hours, from request to completion 6.27 hours, and from fall to x-ray 20.23 hours. 73% had surgery within 36 hours.

Discussion:

This audit highlights significant delays in the diagnosis of hip fracture and sub-optimal analgesia. There is scope for a standardised post-fall management algorithm for doctors to optimise the care of older patients with an inpatient fall sustaining injury.  

References:

1. NAIF annual report 2022 Royal College of Physicians

Introduction

The patients most often admitted with a hip fracture are older adults, many of whom are frail. The Scottish Hip Fracture Standards recommend that all patients have fluid assessment and are mobilised by the end of day 1 post operatively. We set out to look to see which patients are most at risk of acute kidney injury (AKI) and orthostatic hypotension (OH) post operatively and whether this was linked to the prescription of iv fluids (IVF).

Method

All online notes of patients admitted with a hip fracture in the months of July and November 2022 were reviewed. Notes were reviewed for type of anaesthesia (General Anaesthetic or spinal), frailty score (using Rockwood), presence of AKI on days 1-3 post operatively (as determined by looking at lab results), and presence of orthostatic hypotension on days 1-3 post operatively (as documented in physiotherapy notes).

Results

There were 120 patients audited (July: 59; November: 61). 39 patients had IVF prescribed post operatively, 15 developed orthostatic hypotension and 20 developed an AKI. The frailest patients (Rockwood 6/7) were most likely to be prescribed fluids post-operatively (25/52) however had the highest rate of AKI (12/52). Moderately frail patients (Rockwood 4/5) were less likely to be prescribed IVF (8/42) and most likely to develop orthostatic hypotension (9/42) even compared with the frailest patients (3/52). This did not differ by operation type as the same proportion received IV fluids with a spinal (11/30) or general anaesthetic (28/86). Antihypertensives were not linked to AKI but were to OH.

Conclusion

Moderately frail patients are the group that appear most likely to develop post operative orthostatic hypotension but are not prescribed post operative fluids as frequently as the most frail. This may be leading to increased risk of orthostatic hypotension and thereby delay rehabilitation in a vulnerable group.

Introduction

Rib fractures are very common worldwide, particularly in the elderly due to the increased risk of fragility fractures. They are associated with significant morbidity and mortality, largely due to respiratory complications secondary to pain. For each additional fracture in the elderly, mortality increases by 19% and the risk of pneumonia by 27% . It is therefore crucial that recognition and effective analgesia is done promptly. This quality improvement project aimed to assess demographics and management of patients presenting to the Emergency Department (ED) at Weston General Hospital (WGH) with rib fractures.

Methods

Data was collected over a one-year period from 1/09/2021. A total of 199 patients were diagnosed with rib fractures and a random selection of 57 patients' data was analysed using basic statistics.

Results

The average age was 68. 93% had unilateral fractures and 59% had either one or two rib fractures. However, only 9% had severity scores recorded. Despite 29% having a pain score of 8 or more, there was no recorded analgesic prescription for 22% of patients. Of those that did receive analgesia, 33% received strong opioids.

Conclusion

Our data showed that there is scope for improvements in calculation of severity scores and analgesia, and therefore hopefully a reduction in complications. Following this data collection, new guidelines on rib fracture initial management have been produced and implemented at WGH. Going forward, we hope the new guidelines will provide a clear pathway for appropriate assessment and management for different severities of rib fractures, thus improving patient care.

Introduction. Concerns about falling are common among older adults. Many older adults with concerns about falling will restrict their activities. This can trigger a vicious cycle of physical deconditioning, falls, social isolation, reduced confidence, and a loss of one’s sense of self. However, not every older adult with concerns about falling will restrict their activities. In this prospective cohort study we therefore investigated the factors that predict the development of activity restriction due to concerns about falling in older people aged ≥75 years.

Methods. Data were collected as part of the Community Ageing Research 75+ (CARE75+) study. For the baseline (T1) timepoint, we extracted data for 543 older adults who did not report activity restriction due to concerns about falling completed a set of physical and psycho-social assessments. We then assessed which baseline variables predicted the onset of activity restriction at T2 (12-months later).

Results. Of the total sample, 55 older adults reported to have started to restrict activity due to concerns about falling at T2 (10.1% of overall sample), while 488 people reported to (still) not restrict their activities (89.9%). Three key predictors significantly predicted activity restriction status at 12-months follow-up: greater frailty (Fried Frailty Index; OR=1.58, 95%CI: 1.09-2.30), faller status (experiencing a fall between T1 and T2; OR=2.22, 95% CI: 1.13-4.38) and poorer functional mobility/balance (Timed up and Go; OR=1.08, 95%CI: 1.01-1.15).

Conclusions. These findings show that frailty, experiencing a fall and poorer functional mobility/balance may result in the development of activity restriction due to concerns about falling. Clinicians working in balance and falls-prevention services should regularly screen for frailty, and patients referred to frailty services should likewise receive tailored treatment to help prevent the development of such activity restriction.

Introduction: Falls are a leading cause of mortality and morbidity in older people and the risk of falling is exacerbated by underlying mental health conditions and associated treatments. NICE recommends that people who fall should undergo multifactorial assessment including a post-fall protocol with assessment for injury before being safely moved, a timely medical examination (within a maximum of 12 hours or 30 minutes if fast-tracked), neurological observations (if there is suspicion of head injury or unwitnessed fall) and a medication review. Aim: We aimed to assess the quality of post-falls assessment and documentation in order to identify areas for improvement to reduce potential harm from injuries and implement strategies to reduce further falls. Methods: We identified ten falls over a 3-month period on two old age psychiatric inpatient wards. Data collected from e-notes was analysed for assessment for injuries, medical review, neurological observations and medication review. We also looked whether patients had OT/Physio input post-falls and MDT discussion to determine the likely cause for fall. Results: Only 40% of patients had a medical assessment completed within 12 hours. There was suspicion of head injury in 40% of patients but none of them had neurological observations completed. In 20% of falls, an MDT discussion took place to determine likely cause of fall and patients had their medications reviewed post-falls. Almost 90% had OT/physio input post-falls. Conclusion: We have since conducted a survey among healthcare professionals to identify common knowledge gaps that can be targeted to improve quality of care post-falls and conducted teaching sessions on relevant themes. Feedback has showed participants confidence has significantly improved in post-falls assessment. We have also created a weekly falls review meeting and designed and displayed a post-falls board with all necessary information. We aim to re-audit our practice now that changes have been implemented.

Introduction: The Frailty Intervention Team (FIT) is a multidisciplinary team that provides a service to community based frail adults. This particular service is novel in the sense that it is a hospital based out-patient service as opposed to community based service and has access to rapid diagnostic and intervention services. Aims: The aim of this research is to share and describe the model of this relatively new and novel service for the benefit of other service providers. Method: A prospective database review was performed to provide descriptive data on the service between 2021 & 2022. Variables examined included referral source, MDT members involved on initial assessment and follow up, patient’s objective outcome measures and a history of falls. Result: Between the years 2021 and 2022, 350 new patients and 912 review patients were seen by the team with an additional 139 Medical Assessment Unit consultations carried out also. Of these service users 37.38% were male and 62.61% female. The average Clinical Frailty Score was 4.98 (4.91 men, 5.05 women). This indicates the mean service users is ‘Living with Mild Frailty’ - a cohort that may be otherwise missed by other services. Conclusion: This research highlights the demand for access to out-patient frailty interventions in line with the National Clinical Programme for Older Persons which promotes access to ‘the right person, in the right place, at the right time’.

Introduction

Fracture prevention is a key component in the care of frail patients who fall. Patients that have already fallen and suffered a fractured neck of femur are highly likely to fall again, and have proven themselves high risk for fracture. Bone protection is a priority, and recent guidelines recommend IV Bisphosphonates as an appropriate 1st line drug. Vitamin D level should be 50 or above before this is given.

Method: I audited the notes of 41 patients age 60 years or over who were admitted in 2022 with a fractured neck of femur. I reviewed their admission Vitamin D level, and whether they required loading with Vitamin D before IV Bisphosphonates could be given. I reviewed the loading regime used, and how many of the patients had received bone protection medication, either as an inpatient or post-discharge. I liaised with 3 other neighbouring trusts to find out their current Vitamin D loading regimens to compare to our own.

Results: The audit identified that 54% of those patients required Vitamin D loading before they could be given IV Bisphosphonates. 36% of those never had their loading regime prescribed, and of those that did all were prescribed a 7 week long regime. 1 patient was already receiving IV Bisphosphonates prior to admission, and continued on those. 4 Patients were prescribed PO Bisphosphonates. 4 patients were Fast-Track or EOL. 7 patients had low CrCl preventing use of bisphosphonates. Of those that remained, none got inpatient treatment.  I identified that the long loading regime was proving a barrier, and so drafted a new rapid loading guideline, similar to the practice of nearby trusts. Re-audit to assess the impact of this will be performed in July & August 2023 with results presented at conference

Abstract: Ageing is a complex biological process that is progressive in nature. There is a decline observed in the muscle mass and the sensorimotor systems which may contribute to decreased balance and stability while walking.Balance is one of the most crucial intrinsic risk factor for the occurrence of falls. Falls are the leading cause of fatal and non fatal injuries among the elderly.Multiple studies indicate that a structured exercise program helps in improving balance and reducing risk of falls.Exercises can be performed on land as well as in water.Thereby the need of the study to evaluate the effect of land vs aquatic exercises on balance in the elderly.

Method :A Randomised Control Trial with 40 elderly’s selected based on the inclusion criteria; randomly divided in 2 groups. Balance was assessed using Tinetti POMA scale. Exercises were done 3 times a week on alternate days. Below are the walking activities: Walking forward 11 feet. Marching forward 11 feet. Sidestepping without crossing legs 11 feet. Tandem walking 11 feet. Below are the exercise activities. Marching in place. Hip flexion/extension .Hip abduction/adduction. Toe raises/heel raises. Shallow knee bends. Sit to stand from chair in land group. Sit to stand from pool shelf in aquatic group.

Results :Wilcoxin pair signed rank test was used for within group pre and post analysis, for land exercise the two tailed p value <0.0001, which is extremely significant; for aquatic exercises the two tailed p values < 0.0001, which is extremely significant.For between group analysis Mann Whitney Test was used, the two tailed p value < 0.0001, which is extremely significant.

Conclusion:The results show that there is an improvement in balance post both land and aquatic exercises individually, but when compared between the two mediums aquatic exercises showed a better result.

Index terms : Land exercises, Aquatic exercises, Balance in elderly, reduce risk of fall

Introduction

Keeping our standing balance is a crucial capability in preventing falls. Nevertheless, older adults may focus attention internally to their movement mechanisms during stance, through conscious movement processing (CMP), when facing balance difficulties. However, this may interfere with movement automaticity that could cause balance problems. The primary aim of this pilot study is to examine the effects of attention focus balance training on CMP propensity in older adults at risk of falling.

Method

Twenty-four older adults (mean age = 79.92 ± 7.61) with moderate to high risk of falling were included in this preliminary analysis. Participants were randomly assigned to either the No Specific Attention Focus Balance Training Group (NBTG; n=8), External Attention Focus Balance Training Group (EBTG; n=8), or the Internal Attention Focus Balance Training Group (IBTG; n=8). Participants in different groups participated in twelve tailor-made 45-minute training sessions with different attention focus instructions during standing balance training. The primary outcome measure of the real-time (state) CMP propensity (T3-Fz Electroencephalogram (EEG) coherence) at the baseline (T0) and after completion of all balance training sessions (T1) was evaluated. A 3x2 Group (NBTG, EBTG, IBTG) x Time (T0, T1) mixed Analysis of Variance (ANOVA) was conducted.

Results

We discover a decreasing trend of the real-time (state) CMP propensity (T3-Fz EEG coherence) in the EBTG but an increasing trend of the T3-Fz EEG coherence in the IBTG from T0 to T1. The T3-Fz EEG coherence for the NBTG remains similar from T0 to T1.

Conclusion

This preliminary result suggests that the external attention focus balance training has a potential to mitigate the real-time (state) CMP propensity in older adults at risk of falling. Consequently, it could further benefit the standing balance of the at-risk older adults after their rehabilitation.