Joints

Introduction

Old age psychiatry wards facilitate patients who have physical health needs alongside mental health needs, deeming them high risk for falls. Following a fall, best practice suggests a doctor should perform a medical review. An audit of this was performed within the Harplands Hospital in-patient elderly care psychiatric ward, which revealed incomplete documentation or the absence of a review. Subsequently, a post-falls proforma was implemented and a re-audit was performed.

Method

Audit cycle one gathered data on post-falls documentation between August and September 2020. A falls proforma was then introduced and cascaded to ward staff. Audit cycle two then gathered data on post-falls documentation between November and December 2021. Information collected included if falls occurred within normal working hours (Monday-Friday, 09:00-17:00), whether witnessed or unwitnessed, if an assessment was documented, whether a head injury occurred, whether anticoagulation status was documented, and whether neurological observations were completed.

Results

The first cycle showed a total of 31 falls. Insufficient documentation was recorded in 5 falls (16.1%), including 2 falls (6.5%) with no documentation of a physical assessment. A head injury was recorded following 25% of falls, with anticoagulation status documented in 100% of cases. The re-audit showed a total of 10 falls. All falls (100%) were reviewed by a doctor with documentation recorded, including a brief history and assessment. A head injury was recorded in 4 cases (40%), with anticoagulant status only being documented in one case (25%).

Conclusion

This audit demonstrated the implementation of a falls proforma improved post fall documentation. It was noted that the falls proforma was not always utilised, which was thought to be due to junior doctor rotational changes alongside lack of communication regarding this tool. Moving forward, this second cycle identified the need for proforma digitalisation and junior doctor education at induction. 

Fractures occurring after “low energy trauma” are described as fragility fractures. They most commonly happen in the spine, hip and wrist due to osteoporosis and its associated risk factors, including gender, age, medications (e.g. steroids), etc (1). Menopause in women also has a drastic impact on the risk of osteoporosis. In 2019, 3,775,000 UK citizens had a diagnosis of osteoporosis - 820,000 men and 2,955,000 women. In the same year, there were 527,000 new fragility fractures in the UK (2). Nevertheless, osteoporosis and fragility fractures do not only pose a problem within the UK. It is estimated that the number of hip fractures worldwide will increase by 4,600,000 between 1990 and 2050 as a result of an ageing population (3). The percentage of the world's population over the age of 60 is projected to rise from 12% to 22% between 2015 and 2050 (6). This age shift in particular will bring on challenges as the risk of hip fractures doubles every 10 years after the age of 50 (3). Fragility fractures can have a drastic effect on patient well-being. Surgery for hip fractures for instance has a 4% mortality rate and approximately 20% of patients die within a year (3). Patient mobility, housing conditions and quality of life all deteriorate after hip fractures (4). The impact on health economics is also significant. Direct medical costs resulting from fragility fractures in the UK were approximated at £1.8 billion in 2000 and were projected to rise to £2.2 billion by 2025 (1). However, newer reports have shown that we underestimated this burden with the total annual cost of fragility fractures in the UK reaching £4.4 billion in 2022 (5).

Introduction:

Around 10% of calls received by English ambulance services are for older adults who have fallen¹; with an ageing population there are significant care provision needs. Decision-making on the treatment for people who fall, can impact their future physical and mental health. Previous research in decision-making of ambulance staff found perception of role, confidence, service demands and training to be key drivers². Previous work highlights drivers, but not experiences that explain why they occur.

Aim: to determine the experiences and confidence of frontline emergency clinicians in attending older adults who have fallen.

Method:

Online cross-sectional survey of frontline ambulance staff from one English ambulance service in May 2023. Including open questions that generated qualitative data for thematic analysis³. Ethical and regulatory approvals, and informed consent, were obtained.

Results:

81 participants completed the survey. Analysis identified three themes:

Care Pathways: Provision of hospital avoidance pathways varies throughout the region. Concerns arose from not knowing what different areas had and reduced accessibility out of hours.

“Only issue does arise when it’s between 1700 and 0900, as there’s very very limited alternative pathways” P6

Shared Decision-Making: Patients, family and clinicians were all valued as part of shared decision-making, with past feedback on decision-making informing future practice. 

Communication: Decision-making confidence was impacted by the participants experiences; positive experiences encouraged use of hospital avoidance pathways, whilst negative experiences impeded willingness to avoid hospital for fear of repercussion.

"Many services are helpful and willing to assist with education for hospital avoidance.” P18

Conclusion:

Prominent themes arose from the challenge of a regional and 24/7 ambulance service, not having consistent pathways available. This variation led to concerns when responding to patients outside of the clinician’s usual area and further challenges ambulance clinicians must balance in their practice.

References:

1. Snooks, Anthony, Chatters, et al. (2017) Health Technology Assessment, 21; 1-218.

2. Simpson, Thomas, Bendall, et al. (2017) BMC Health Services Research. 17; 299.

3. Braun and Clarke. (2006) Qualitative Research in Psychology, 3; 77-101.

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:

Constipation is common in older individuals and becomes prevalent in elderly inpatients. Those recovering from a hip fracture experience worsening constipation due to poor mobility, changes in diet and hydration, general anaesthesia and opioid use. This study explores the feasibility of the pelvic radiographs (PXR) already available in this population in assessing the severity of constipation in order to guide post-operative bowel management. AIM: To evaluate the effectiveness of diagnosis and management of constipation based on PXR findings of elderly patients presenting with hip fracture.

METHODS:

Retrospective analysis of consecutive patients aged 65 and above admitted with hip fracture to our hospital over a 5-week period. Patients without a PXR or experiencing severe complications were excluded. PXRs, medical records, drug charts and bowel charts were reviewed. Constipation was graded from 1+ to 3+ based on faeces in the sections of large bowel and rectum seen on PXR. A specific combination of oral and rectal laxatives was used based on such grading. The average time taken for the bowels to function was compared between patients with protocol-compliant management, minimally deviated management and non-compliant management.

RESULTS:

46 patients were included. Those with bowel management in line with our protocol (23) achieved bowel movement 1.7 days after surgery on average. By contrast, patients with minimal (9) and major deviations (14) from our protocol had a bowel movement respectively 3.6 and 4.2 days after surgery.

CONCLUSION:

These findings highlight the benefits of utilising admission PXRs in elderly patients with hip fracture to grade and manage constipation and, hence, reduce hospital stay and complications. Patients managed in line with our protocol experienced bowels functioning in less than 2 days, compared to over 4 days for patients with major deviations.

Introduction:

Falls in older people are associated with multifactorial risks which are often preventable. Last year there were over 220,000 emergency admissions for falls in people aged 65 years and over in the UK. Improving how we assess such patients on admission may help to ameliorate these risks and prevent future admissions.

Method:

The aim of this quality improvement project was to identify weaknesses in our acute risk assessment of multifactorial falls and to improve on these. We completed a retrospective case note review for 68 patients in their first 48 hours of admission. As an analytical framework, we adopted the NICE guideline: ‘Falls in older people: assessing risk and prevention’ which details twelve key parameters of risk assessment. For each patient we sought to determine whether these parameters were assessed or missed. After the first audit cycle, we found four guideline parameters which were commonly missed during the acute admission phase. An educational intervention was subsequently organised for medical staff at a departmental level and corroborating posters were placed around the acute areas of the hospital. Two months later a second audit cycle was undertaken which assessed the same parameters and looked for improvement.

Results:

There were notable improvements in four areas. The assessment of visual impairment increased from 32.4% to 42%. The documentation of patients’ perceived risk of falling improved from 37.3% to 60.9%. Osteoporosis risk assessment rose from 32.4% to 63.8%. The completion of Lying/Standing BP demonstrated the most significant increase, from 14.7% to 44.9%.

Conclusions:

The results suggest that a tailored educational session and a poster campaign have increased overall awareness and improved the risk assessment of multifactorial falls at a central Birmingham Hospital.

Introduction:

Dizziness and vestibular symptoms are common in older adults. However, many older adults do not seek assistance for these symptoms. This study set out to explore the barriers and enabling factors to accessing healthcare in this population.

Method:

Semi-structured, one to one interviews were undertaken via video conference. Older adults (≥65 years old) were recruited organisations that support older adults, via purposeful sampling to recruit participants with a range of severity of vestibular symptoms (measured using the dizziness handicap inventory) alongside those who had and hadn’t sought help for their symptoms. Data was analysed using a reflective thematic analysis approach. Findings: 16 older adults (Mean age 74) were interviewed via zoom. The majority were female (76.5%) and White British (88.3%). The following themes were identified in the data set. 1) “Sometimes I feel dizzy if the vertigo is really bad” This theme describes the challenges with describing dizziness and vertigo, alongside the range of presentations experienced by participants. 2) Accessing Healthcare: This broad theme describes a range of personal and systemic barriers that participants experienced when accessing healthcare for their vestibular symptoms. This theme has been split into subthemes exploring the personal, service level and health professional barriers experienced by participants

Conclusion:

This study has highlighted that dizziness and vertigo are ambiguous terms and therefore clear communication is needed to ensure a shared understanding between health professionals and older adults. Barriers to healthcare exist at a personal, service level and health professional level for this population. Further work is needed to break down these barriers and improve access to healthcare for this population.

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 order to improve resident safety and reduce hospital admissions, the ‘Optimizing Bed Height Quality Improvement Study’ aims to raise awareness among healthcare professionals about the importance of ensuring optimal bed height to prevent falls and injuries in residents and to improve bed mobility.

The parameters from a 2015 study, ‘Analysis of the Influence of Hospital Bed Height on Kinematic Parameters Associated with Patient Falls During Egress', are taken into account when using intervention techniques.

METHODS: Residents aged 65 or over falling out of bed between January and June of 2022 were used as a pre-test measure. By maintaining a hip or knee angle just above 90 degrees, keeping the resident's feet flat on the floor, and ensuring that they can easily transition from sitting to standing and vice versa, the nurse and physiotherapist assessed the resident's mobility and determined the height of the resident's bed. An illustration of the ideal height is displayed on a poster that hangs on the wall above the headboard of the bed. Nurses visit each resident's room each day to ensure that the beds were in the ideal position and record this information in the monitoring system. The data obtained during the six-month period of intervention (July to December 2022) was compared with the pre-test results.

RESULTS: Results from a six-month intervention period (July to December 2022) were compared to those from a six-month pre-intervention phase (January to June 2022) with fourteen bed falls, there was a FIFTY PERCENT decrease in bed falls.

CONCLUSION: After a six-month clinical trial, the study revealed that older adults who had bed falls and trouble getting out of their beds had lower fall rates, suggesting that stakeholders' knowledge of the ideal bed height had increased.

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.