Respiratory

Background: The disease burden of respiratory syncytial virus (RSV) in older adults is substantial but not well quantified previously. We aimed to estimate country-specific hospitalisation burden of RSV-associated acute respiratory infection in older adults (>60 years) in Europe.

Methods: We collected published data (through a systematic review) and unpublished data (from GSK-sponsored studies and international collaborators) on RSV hospitalisation burden. We used multiple imputation for missing age bands. We applied stepwise statistical adjustment to account for case underascertainment related to the variations in case definitions, clinical specimens and RSV diagnostic tests in individual studies. We reported country-level RSV hospitalisation rates for countries with ≥1 eligible study reporting point estimate and 95% confidence interval (CI) of the rates (a random-effects meta-analysis was conducted when ≥2 studies were available). As an alternative method, we additionally included studies not reporting 95% CI and calculated the median of the rate point estimates.

Results: Seven studies were included from five countries: Denmark (1), Finland (1), Netherlands (1), Spain (1) and UK (3). Denmark and Spain had the highest and lowest adjusted RSV-associated hospitalisation rate (408/100000, 95% CI: 319-516; and 176/100000, 137-226) in >60 years, which was about 2.4 times the unadjusted estimate. The alternative method with 5 more studies added had similar estimates for the five countries; another country (Norway) was added and it had the highest adjusted hospitalisation rate (742/100000). RSV-associated hospitalisation rate increased with increasing age across all countries.

Conclusions: With RSV vaccines now approved for use in older adults, our findings help inform the need for country-level RSV prevention.

Introduction

High-dose corticosteroids have significant benefits for infective exacerbations of COPD, reducing risk of relapse, length of hospital stay and earlier symptom improvement. However, recurrent use has been shown to increase risk of comorbidities including osteoporosis, type two diabetes mellitus (T2DM), cardiovascular disease, hypertension, and elevated body mass index (BMI). 

This audit assessed how many patients at Anchor Mill Medical Practice in Paisley, who had been prescribed two or more courses of prednisolone in the six months prior to the start of data collection, had been assessed for T2DM, renal impairment, elevated BMI, hypertension and osteoporosis within the previous year. 

Methodology 

An EMIS search was performed for patients over eighteen who were coded as having COPD and who had received two or more acute prescriptions of prednisolone from 03/04/2023 to 03/10/2023. 

Data was then collected from the patient's medical summaries and investigations, looking at if they had had HbA1c, urea and electrolytes, lipids, BMI and blood pressure checked within the preceding year. The audit also looked at how many patients had had a QFracture score calculated over the past year, or if they had been referred for or had had a DXA scan within the previous five years. 

Results 

Over 50% had had their lipid profile and HbA1c checked, with over 75% having had their U+Es, BMI and BP checked. The major outlier was OP risk assessment, for which only 31.25% of patients had been screened. 

Conclusions 

Within this primary care setting, improvements could be made on screening for associated comorbidities with COPD. The patients were referred for these investigations, with the biggest improvement being a 140% increase in patients referred for a DXA scan, and annual follow up with the practice nurse was changed to include these investigations as appropriate.

Introduction -

The British Thoracic Society Guidelines 2017 recommends oxygen delivery to achieve target oxygen saturation range between 94% and 98% of the majority of medically unwell adult patients, and 88% to 92% in patients at risk of hypercapnic respiratory failure. Oxygen is a drug which should be prescribed for patient’s just like any other medication and is often over-looked. For some older people oxygen treatment can impair mobility, increase deconditioning and the risk of falls. We conducted a re-audit and PDSA cycle expanding from one ward (Eashing) to all three geriatrics wards over a 9-week period, to assess and improve compliance and patient safety.

Method -

A retrospective approach gathered data on a weekly basis, using all listed in-patient electronic medical records. Patient’s identified as having an oxygen requirement after first contact with a consultant when new to the wards, were reviewed as to whether oxygen was prescribed or not. A 5-week baseline audit and then one PDSA cycle over 4 weeks was implemented; with baseline results disseminated to the ward MDT’s with posters placed in each ward, 2 weeks later ward consultants and junior doctors were e-mailed.

Results -

5-week baseline audit; total patient population: 47. Eashing 11/16 patients = 68%. Elstead 1/14 patients = 7%. Hindhead 0/17 patients = 0%. 4 weeks following PDSA cycle completion; total patient population: 25. Eashing 8/9 = 88%. Hindhead 7/11 = 64%. Elstead 2/4 = 50%.

Conclusion -

Improvement in oxygen prescription compliance was noted across all wards, a clear upward trajectory in the results. On Eashing, teamwork and the involvement of nurses and their help was key to the improvement and highest compliance rate. The main barrier to sustainability is the rotation of new junior doctors, mitigated for through MDT dissemination & posters as well as consultant awareness.

The commonest nosocomial infection in the UK is Hospital Acquired Pneumonia (HAP), associated with prolonged length of stay and mortality. The HAP incidence on Elderly care wards was > 5% of admissions, exceeding the national average. An initiative ‘Mind the HAP’ was launched which included doctors, nurses, pharmacists, SLTs, physiotherapists and coders to improve HAP diagnosis, management and prevention. Methods: To monitor the effectiveness of the interventions 3 audit cycles were performed between 2019 and 2023. Several interventions were implemented between 2019 - 2023.A multidisciplinary steering committee was formed with 3 work streams (diagnosis, management and prevention). To improve the accuracy of diagnosis and management of HAP, focused educational sessions were conducted for junior doctors with monthly meetings with coders. Nurses championed implementing the HAP prevention strategies i.e. hand hygiene, mouth care and positioning at 30-45 degrees. Regular comprehensive training sessions were held. HAP awareness and education campaign was launched. Daily nursing huddles helped to identify high risk patients. Physiotherapists provide chest physiotherapy to yield sputum sample collection among pneumonia patients. An electronic dashboard of incidence of HAP against the preventative measures and sputum culture reports has been launched with help from informatics. Information leaflets on HAP were created for patient awareness. An electronic HAP power plan to facilitate diagnosis and management of HAP will be launched from February 2024. Results: HAP incidence has dropped to < 2 %, diagnostic accuracy improved from 35% to 81%, and sputum collection has increased from 9% to 24%. The HAP Quality Improvement Project received first prize for the most impactful Quality Improvement initiative at the Trust-wide conference in 2023. The results have been shared with the regional Microbiologists. The collaborative efforts coupled with effective leadership and guidance, have been pivotal to the success of "Mind the HAP" project.

Introduction: Aspiration pneumonia is a common condition, particularly in older patients, with impaired swallowing being a significant risk factor; however, it can be difficult to recognise and no specific management guidance existed nationally until the British Thoracic Society Clinical Statement was published in March 2023. In this audit, we assessed the management of patients admitted with aspiration pneumonia to Leighton Hospital, Crewe.

Methods: We retrospectively collected data from a random sample of patients ≥64 years old admitted to the Acute Medical Unit with aspiration pneumonia between September and November 2022. Data collected included length of stay, co-morbidities, presence of an EDAR (Eating and Drinking At Risk) decision, antibiotics prescribed, completion of SLT (Speech and Language Therapy) review and mortality outcome. Antibiotic prescribing practice was compared against local trust guidelines. 

Results: 24 of the 28 patients were prescribed antibiotics; of these, only 12 (50%) followed Trust guidelines. Regarding nutrition, 29% of patients did not have a clear plan for EDAR or an alternative feeding method. 14% of patients were not referred to SLT when it may have been appropriate. 

Conclusions: For this patient cohort, adherence to local antimicrobial guidelines was only 50%. Reasons for this divergence may include human factors such as lack of awareness of guidelines, and system factors including rotation of doctors through different trusts. Subsequently, posters have been displayed in clinical areas where patients are clerked and initially managed. Regular re-audits will be performed to evaluate whether guideline adherence has improved and to implement new changes accordingly.

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.