92 CONTINUING TO ‘BE HIP’: ORTHOGERIATRIC SERVICE IMPROVEMENTS IN 2021

Background

Scotland first demonstrated that adherence to nationally agreed hip fracture standards improve patient survival, reduces the duration of admission, and reduces the need for high dependency care. Our study aims to assess adherence to the Irish Hip Fracture Standards (IHFS) in our hospital for 2021 amidst the COVID-19 pandemic, translating to improved clinical outcomes for our patients.

Methods

The IHF database was retrospectively analysed, comparing quarters 1-4 in 2021 with our 2020 results.

Results

IHFS1, patient time to the ward < 4hours, was maintained at 67% in 2021 versus 71% overall in 2020. There was improvement in IHFS2, time to surgery within 48 hours, up to 73% in 2021 versus 66% in 2020. IHFS3 was 4% in 2021 versus 3% overall in 2020. Further improvements were noted for IHFS4, with 95% of patients reviewed by a Geriatrician in 2021 versus 87% in 2020. IHFS5 also improved with 97% of patients receiving a bone health assessment in 2021 versus 87% in 2020. Moreover, IHFS6, improved with 97% of patients undergoing a specialised falls assessment in 2021 versus 87% in 2020.

Conclusion

The improvement in 2021 figures is reflective of the return of redeployed services during the COVID-19 pandemic inclusive of the Orthogeriatric Service, the Fracture Liaison Service Advanced Nurse Practitioner, the Trauma Co-ordinator, and the specialist Orthopaedic ward complete with its Orthopaedic nurses and Multi-Disciplinary Team, and improved Emergency Department pathways. These continued improvements in the IHFS further emphasise that success is dependent on a team that is joined at the hip

258 RISING TO THE CHALLENGE: ORTHOGERIATRIC SERVICE IMPROVEMENT AND COVID-19

Background

Nationally agreed hip fracture standards have contributed to the improvement of outcomes in hip fracture patients. In 2020, our hospital was awarded “The Golden Hip” for achieving highest compliance with Irish Hip Fracture Standards (IHFS) nationally for 2019.

Methods

Data from the Irish Hip Fracture Database (IHFD)was retrospectively analysed to assess our performance in 2020 versus 2019 in hip fracture patients over sixty. Multiple quality improvement interventions were put in place throughout 2019 to ensure improvement in IHFS1-6 compliance: Creation of the Hip Fracture Pathway Subgroup, IHFS 1 Breaches Audit, Orthogeriatric input at Orthopaedic inductions, weekly Multi-disciplinary Team meetings, a Nutritional Hip Fracture Pathway and addition of the Fracture Liaison Service Advanced Nurse Practitioner.

Results

There were 239 hip fracture patients in 2020 vs 249 in 2019. IHFS1 compliance improved with the percentage of patients admitted to the Orthopaedic ward within 4 hours increasing to 71% in 2020 from 56% in 2019. There was improvement in IHFS2-time to surgery &lt;48 hours- 66% in 2020 vs 60% in 2019. IHFS3-pressure ulcer rate-was at the national average, 3% in 2020 vs 2% in 2019. IHFS4 (reviewed by a Geriatrician), IHFS5 (received a bone health assessment) and IHFS6 (received a specialised falls assessment) were lower overall; 87% in 2020 vs 98% in 2019. For all quarters (Q),43% of patients met all IHFS in our hospital in 2020 vs 32% in 2019, resulting in €90,000 in Best Practice Tariff funding.

Conclusion

Lower results for IHFS 4,5 and 6 reflect the arrival of the COVID-19 pandemic which led to redeployment of the Orthogeriatric Service and redeployment of the MDT from end of Q1 to Q3. When services in 2020 were preserved,1 in 2 hip fracture patients met all IHFS, vs 1 in 3 patients in 2019. Despite the pandemic, we continued to achieve the highest level of IHFS compliance nationally, being awarded a second consecutive “Golden Hip” for 2020.

103 ORTHOGERIATRIC SERVICES IN THE FACE OF COVID-19

Background

Nationally agreed standards improve the level of care delivered to all older, frail, multi-morbid patients presenting with hip fractures. Dedicated Orthogeriatric services allow for these standards to be achieved in a multi-disciplinary team (MDT) setting. As the COVID-19 pandemic reached our shores, the model of care set out by the Irish Hip Fracture Standards (IHFS) was under threat. Our dedicated Orthopaedic Trauma ward became an acute COVID ward and the Orthogeriatric service was re-deployed to acute medicine for Quarter 2.

Methods

Using the Irish Hip Fracture Database, local data was analysed and compared with national data from Quarter 1 to 4 (Q1–4) in 2020.

Results

When comparing local IHFS’s with national figures, ongoing challenges and future goals are highlighted.

In 2020, there were 222 hip fracture patients (mean age 81.8 years) in our hospital. Standard 1, time to the ward <4 hours, stands at 71% locally (national average 33%). Standard 2, time to theatre <48 hours, is an ongoing challenge and remains at 66% (national average 75%). Standard 3, pressure ulcer rate, was the same as the national average at 3%. Standards 4, 5 and 6 in our hospital stand at 87% (national averages of 82%, 91% and 85% respectively).

In Q1, 56%, or over 1 in every 2 patients with hip fractures, met all of the Irish Hip Fracture Standards in our hospital. In Q2, only 18% of patients met all of the IHFS’s. Q3 saw improvements with 47% of all hip fracture patients achieving all IHFS’s. Q4 showed maintenance with 45% of all patients achieving all IHFS’s.

Conclusion

These findings highlight the need for a dedicated Orthogeriatric Service and Orthopaedic ward at all times. Going forward with the risk of future waves and the emergence of new variants, every effort should be made to maintain a comprehensive orthogeriatric service to minimise a negative impact on patient care.

Factors influencing delayed presentation of breast cancer at a tertiary care hospital in Pakistan

BACKGROUND

Breast cancer is the leading cause of death despite the continuous development of newer and more effective modalities of treatment for breast cancer. In Asia, Pakistan has the highest rate of breast cancer. Breast cancer treatment shows better prognosis when it is diagnosed at an early stage, but mortality increases significantly with delayed diagnosis and advanced stage of disease. Delay in diagnosis and nonavailability of treatment are the major factors responsible for advanced stage and low survival.

AIMS

The objective of our study was to identify the factors responsible for delayed presentation of patients with breast carcinoma.

METHODS AND RESULTS

A cross-sectional study using a questionnaire method was conducted at the Foundation University Medical College from January 2015 to December 2016. A total of 89 patients gave consent and were interviewed using a prestructured questionnaire during the study. Age ranged from 25 to 64 years. Majority of patients were in stage T3N1M0 (31.5%). Second most common stage was T4N0M0 (14.6%). Thirteen patients (12.4%) were in stage T3N0M0, and 10 patients (11.2%) were in T3N2M0. Delay ranged from 3 months to more than 1 year; 43.8% presented with delay of 3 to 6 months. The reasons for delay were lack of knowledge about breast cancer (41%), lack of availability of health care services (32.6%), purdah and religious reasons (6.7%), and fear of being diagnosed with cancer (10.1%).

CONCLUSION

The main reasons for delay identified in our study were lack of knowledge and availability of appropriate health care facilities. In order to improve outcome of breast cancer, more focus is needed on spreading awareness and improving health care services in rural areas.

Frequency of corneal dystrophies on the basis of histopathology in surgically removed corneas

OBJECTIVE

To assess the frequency of corneal dystrophies on the basis of histopathology in surgically-removed corneas.

METHODS

The descriptive study was conducted at Foundation University Medical College, Islamabad, and Al Shifa Eye Hospital, Rawalpindi, Pakistan, from May to October 2011, and comprised post-keratoplasty corneal specimen irrespective of age and gender. The surgically-removed corneas were processed according to the standard guidelines of histopathological processing. The histopathological sections were examined for various corneal dystrophies. Data was recorded on a proforma and was analysed using SPSS 17.

RESULTS

Of the 63 patients in the study, 12(19%) were diagnosed as having corneal dystrophies. In these 12 patients, 6(50%)were diagnosed as stromal corneal dystrophies and 5(42%)had posterior corneal dystrophies, and 1(8%)had anterior corneal dystrophy.

CONCLUSIONS

Histopathological examination of corneas is a reliable method to diagnose and classify corneal dystrophies.

The interobserver reproducibility of thyroid cytopathology using Bethesda Reporting System: analysis of 200 cases

OBJECTIVE

To determine interobserver reproducibility of thyroid cytopathology in cases of thyroid fine needle aspirates.

METHODS

The retrospective, descriptive study, was conducted at the Foundation University Medical College, Islamabad, using cases related to period between 2009 and 2011. A total of 200 cases of fine-needle aspirations were retrieved from the archives. Three histopathologists independently categorised them into 6 groups according to Bethesda reporting system guidelines without looking at previous reports. Kappa statistics were used for analysis of the results on SPSS 17.

RESULTS

Of the 200 patients, 194 (97%) were females and 6 (3%) were males. The overall mean age of patients was 46 +/- 20 years. Kappa value calculated for observer-1 and observer-2 was 0.735; for observer-1 and observer-3, 0.841; and for observer-2 and observer-3, 0.838, showing substantial interobserver agreement. Histopathological correlation was available, for 39 (19.5%). Of these cases, 5 (13%) were 'non-diagnostic, 20 (51%) 'benign, 2 (5%) 'atypia of undetermined significance/follicular lesion of undetermined significance, 6 (15%) 'follicular neoplasm, 1 (3%) 'suspicious for malignancy, and 5 (13%) 'malignant.

CONCLUSIONS

Good overall interoberver agreement was found, but discordance was seen when certain categories were analysed separately.

The performance of routine computed tomography for the detection of colorectal cancer

INTRODUCTION

Although colonoscopy and computed tomography (CT) colonography in expert hands are the most sensitive investigations for colorectal cancer, some patients may not tolerate the necessary bowel preparation and insufflation of gas into the colon. We assessed the performance of unprepared contrast CT for the detection of colorectal cancer.

METHODS

A retrospective review was undertaken of all patients who had contrast CT of the abdomen and pelvis and then went on to have colonoscopy at our institutions between 2007 and 2010.

RESULTS

Overall, 96 patients were identified as having had CT prior to colonoscopy. The sensitivity of CT in detecting colorectal cancer was 100% (95% confidence interval [CI]: 19.8-100%) and the specificity was 95.7% (95% CI: 88.8-98.6%). The positive predictive value was 33.3% (95% CI: 6.0-75.9%) and the negative predictive value was 100% (95% CI: 94.8-100%).

CONCLUSIONS

Non-targeted CT that is negative for colorectal malignancy is usually reassuring but the decision for further investigations should be made on a case-by-case basis, taking into account of the likelihood of underlying colorectal malignancy and the underlying co-morbidities of the patient. However, video colonoscopy is usually necessary to assess positive CT findings.