253 DELIRIUM IDENTIFICATION AT INITIAL TRIAGE IN AN IRISH EMERGENCY DEPARTMENT SETTING

Background

Over 10% of older adults are affected by delirium on presentation to Emergency Departments (ED), with many more developing it during a prolonged ED stay. Early detection is key to delirium management, but the diagnosis is often missed, with over 50% of delirium going undetected in the ED. In 2019 the HSE guideline on Early Identification and Management of Delirium in the ED recommended that all those over 65 years be screened on presentation to ED using the 4AT, a validated instrument in delirium screening. Through our ED’s delirium working group, we conducted a baseline audit on current rates of screening for delirium, ahead of a quality improvement project on management of patients with, or at risk of delirium in our ED.

Methods

A retrospective review was conducted of consecutive patients >65yrs who presented to ED in one month with the following terms mentioned in the presenting complaint at triage: confusion/delirium/memory/speech/language disturbance/agitation i.e. terms that could indicate possible delirium as considered by the triage practitioner. We also recorded whether a 4AT was recorded. An additional 50 charts from the consecutive series were randomly selected and examined for probable delirium on presentation which was not captured at triage.

Results

n=23/1,597 (<1%) had possible delirium recorded at triage as per our criteria. In-depth case note review supported the diagnosis of delirium in 20 of the 23 initially identified at triage. Only 5 of these had a documented 4AT score. Of the additional 50 charts screened, a further 6 had likely delirium of whom n=3 had a 4AT score completed. N=16 required hospital admission.

Conclusion

Delirium screening and detection rates at ED triage are less than expected, and below the 2019 national screening recommendations. Implementing same in any busy ED is challenging. We are developing a multifaceted educational program to address this and plan a repeat audit following implementation.

The experience of blood glucose monitoring in people with type 2 diabetes mellitus (T2DM)

BACKGROUND

Finger prick blood glucose (BG) monitoring remains a mainstay of management in people with type 2 diabetes (T2DM) who take sulphonylurea (SU) drugs or insulin. We recently examined patient experience of BG monitoring in people with type 1 diabetes (T1DM). There has not been any recent comprehensive assessment of the performance of BG monitoring strips or the patient experience of BG strips in people with T2DM in the UK.

METHODS

An online self-reported questionnaire containing 44 questions, prepared following consultation with clinicians and patients, was circulated to people with T2DM. 186 responders provided completed responses (25.5% return rate). Fixed responses were coded numerically (eg not confident = 0 fairly confident = 1).

RESULTS

Of responders, 84% were treated with insulin in addition to other agents. 75% reported having had an HbA1c check in the previous 6 months. For those with reported HbA1c ≥ 65 mmol/mol, a majority of people (70%) were concerned or really concerned about the shorter term consequences of running a high HbA1c This contrasted with those who did not know their recent HbA1c, of whom only 33% were concerned/really concerned and those with HbA1c <65 mmol/mol of whom 35% were concerned. Regarding BG monitoring/insulin adjustment, only 25% of responders reported having sufficient information with 13% believing that the accuracy and precision of their BG metre was being independently checked. Only 9% recalled discussing BG metre accuracy when their latest metre was provided and only 7% were aware of the International Standardisation Organisation (ISO) standards for BG metres. 77% did not recall discussing BG metre performance with a healthcare professional.

CONCLUSION

The group surveyed comprised engaged people with T2DM but even within this group there was significant variation in (a) awareness of shorter term risks, (b) confidence in their ability to implement appropriate insulin dosage (c) awareness of the limitations of BG monitoring technology. There is clearly an area where changes in education/support would benefit many.

147 ‘CHAMPIONING CONTINENCE’—ESTABLISHMENT OF A MULTIDISCIPLINARY CONTINENCE PROMOTION WORKING GROUP IN AN ACUTE TEACHING HOSPITAL

Background

In line with the National Frailty Programme1, patients over the age of 75 admitted to hospital should have a comprehensive geriatric assessment including the assessment of current continence status and any history of incontinence. Up to 39% of adults are reported to develop new onset urinary incontinence during admission to hospital2,3, however studies show that is it a problem not always identified by staff members,4. In response to these observations within an acute teaching hospital, a continence working party was formed involving members of nursing, physiotherapy and occupational therapy colleagues to explore the current practice and culture relating to continence management.

Methods

The group established key objectives which were broken into four strands;

1. Audit of documentation of baseline continence on admission (therapy and nursing).

2. Obtaining access to additional types of continence wear.

3. Staff education.

4. Pre and post education survey.

Results

1. Audit of documentation demonstrated poor standards of documentation of baseline continence. This led to an amendment to questioning prompts on therapy initial assessment forms and a plan to further evaluate the nursing documentation.

2. A wider array of continence wear has been made available on the wards providing greater options for patients.

3. Staff education session was compiled by a specialist physiotherapist and is widely available for staff to access on the hospitals online training portal.

4. Pre-education surveys have been completed with a view to re-administering following education roll-out.

Conclusion

The aim of this multidisciplinary working group is to equip staff with the correct resources, knowledge, and confidence to ensure best practice promotion of continence on the targeted wards. This project is the first strand of a wider culture changed that is needed around continence promotion for older adults in the acute setting.

Health utilities for non-melanoma skin cancers and pre-cancerous lesions: A systematic review

BACKGROUND

Non-melanoma skin cancers (NMSCs) are common and consume many healthcare resources. A health utility is a single preference-based value for assessing health-related quality of life, which can be used in economic evaluations. There are scarce data on health utilities for NMSCs.

OBJECTIVES

Using a systematic review approach, we synthesized the current data on NMSC-related health utilities.

METHODS

A systematic review of studies of NMSC-related health utilities was conducted in Medline, Embase, and Cochrane databases. Data were extracted based on the protocol and a quality assessment was performed for each study.

RESULTS

The protocol resulted in 16 studies, involving 121 621 participants. Mean utility values across the studies ranged from 0.56 to 1 for undifferentiated NMSC, 0.84 to 1 for actinic keratosis, 0.45 to 1 for squamous cell carcinoma, and 0.67 to 1 for basal cell carcinoma. There was considerable variability in utilities by type of cancer, stage of diagnosis, time to treatment, treatment modality, and quality of life instrument or method. Utility values were predominantly based on the EuroQol 5-dimension instrument and ranged from 0.45 to 0.96, while other measurement methods produced values ranging from 0.67 to 1. Lower utility values were observed for advanced cancers and for the time period during and immediately after treatment, after which values gradually returned to pre-treatment levels.

CONCLUSIONS

Most utility values clustered around relatively high values of 0.8 to 1, suggesting small decrements in quality of life associated with most NMSCs and their precursors. Variability in utilities indicates that careful characterization is required for measures to be used in economic evaluations.

People with Type Diabetes Mellitus (T1DM) self-reported views on their own condition management reveal links to potentially improved outcomes and potential areas for service improvement

BACKGROUND

The self-management of type 1 diabetes (T1DM) has moved forward in many areas over the last 40 years. Our study asked people with T1DM what is their experience of blood glucose (BG) monitoring day to day and how this influences decisions about insulin dosing.

METHODS

An on-line self-reported questionnaire containing 44 questions prepared after consultation with clinicians and patients was circulated to people with T1DM 116 responders provided completed responses. Fixed responses were allocated specific values (e.g. not confident = 0 fairly confident = 1). Multivariate regression analysis was carried out. Only those 5 factors with p-value <0.05 were retained.

RESULTS

59% of respondents were >50 years old and 66% had diabetes for >20 years, with 63% of patients reporting HbA1c results ≤8% or 64 mmol/mol. Findings included; 75% used only 1 m; 56% had used the same meter for ≥3 years; 10% had tried flash monitors; 47% were concerned about current BG level; 85% were concerned about long-term impact of higher BG. 72% of respondents keep BG level high to avoid hypoglycaemia; 25% used ≥7 mmol/L as pre-meal BG target to calculate dose; 65% were concerned they might be over/under-dosing; 83% did not discuss accuracy when choosing meter. However 85% were confident in their meter's performance. The factors that linked to LOWER HbA1c included LESS units of basal insulin (p < 0.001), HIGHER number of daily BG tests (p = 0.008), LOWER bedtime blood glucose (p = 0.009), HIGHER patient's concern over long-term impact of high BG (BG) (p < 0.009 but LOWER patient's concern over current BG values (p = 0.009). The final statistical model could explain 41% of the observed variation in HbA1c.

CONCLUSION

Many people still run their BG high to avoid hypoglycaemia. Concern about the longer-term consequences of suboptimal glycaemic control was associated with a lower HbA1c and is an area to explore in the future when considering how to help people with T1DM.

Effect of Stanozolol on Factors VIII and IX and Serum Aminotransferases in Haemophilia

The treatment of haemophilia has been dramatically improved since the introduction of factor VIII and IX concentrates, however these concentrates have brought new problems such as hepatitis and A.I.D.S. An oral agent which could raise endogenous levels of factor VIII and IX would be of great benefit. Danazol, an anabolic steroid, has recently been shown to increase levels of factors VIII and IX in haemophilia. We therefore studied the effect of stanozolol, a closely related anabolic steroid, in 15 patients with haemophilia A or Christmas disease over a 2-4 week period. There was no consistent change in factor VIIIc or factor IX, and fibrinolysis was significantly enhanced. No effect was apparent on the incidence of spontaneous bleeds. However serum aminotransferases which were abnormal in 11 of the 15 patients at the start of the study fell significantly with stanozolol therapy. This raises the interesting possibility that anabolic steroids may be beneficial in patients with chronic liver diseases.

Change in primary health care: new wine in old bottles?

Describes the findings from the first year of an evaluation of change at a PMS+ site in West Cumbria. The study has used qualitative methods including non-participant observation at the site; face to face interviews with 28 clinical staff; group interviews with administrative and secretarial staff; and the collection of documents. Analysis of the data against a set of "outcome indicators" shows that significant progress has been made towards implementing the model of primary care delivery described in the pilot proposal. Multidisciplinary working is developing in the clinical action groups and the establishment of a primary care emergency unit has changed general practitioner workloads. The new organisation structure is not yet working wholly as anticipated but recently initiated changes are intended to strengthen the role and authority of the management board.

The inheritance of abnormal sialoglycoproteins found in a Gerbich negative individual

The Gerbich blood group antigens are probably expressed on one or more of the minor erythrocyte (beta, beta 1, or gamma) sialoglycoproteins which are lacking in some rare individuals having the Gerbich negative phenotype. A monoclonal antibody, CMRF-10, which recognises a trypsin-sensitive site on both the beta and beta 1 sialoglycoproteins, was tested for binding to erythrocytes from a Gerbich negative individual, OM. Erythrocytes from OM bound CMRF-10 in similar amounts to normal erythrocytes even though membranes from OM were shown by sodium dodecyl sulphate-polyacrylamide gel electrophoresis to lack both the beta and gamma sialoglycoproteins found in normal red blood cells. Instead, abnormal sialoglycoproteins which migrated as two bands with apparent molecular weights within the range 29,500-32,500 daltons were identified and purified using CMRF-10. Subsequent electrophoretic analysis of OM's two children failed to reveal any abnormal sialoglycoproteins. This suggests that in this instance the Gerbich negative phenotype may result from other mechanisms, possibly defective glycosylation, rather than a crossover involving the gene coding for the primary protein structure of the sialoglycoproteins.

Effect of stanozolol on factors VIII and IX and serum aminotransferases in haemophilia

The treatment of haemophilia has been dramatically improved since the introduction of factor VIII and IX concentrates, however these concentrates have brought new problems such as hepatitis and A.I.D.S. An oral agent which could raise endogenous levels of factor VIII and IX would be of great benefit. Danazol, an anabolic steroid, has recently been shown to increase levels of factors VIII and IX in haemophilia. We therefore studied the effect of stanozolol, a closely related anabolic steroid, in 15 patients with haemophilia A or Christmas disease over a 2-4 week period. There was no consistent change in factor VIIIc or factor IX, and fibrinolysis was significantly enhanced. No effect was apparent on the incidence of spontaneous bleeds. However serum aminotransferases which were abnormal in 11 of the 15 patients at the start of the study fell significantly with stanozolol therapy. This raises the interesting possibility that anabolic steroids may be beneficial in patients with chronic liver diseases.

The genetic demography of the Gainj of Papua New Guinea. I. Local differentiation of blood group, red cell enzyme, and serum protein allele frequencies

Allele frequencies are reported for 19 blood group, red cell enzyme, and serum protein loci (ABO, Rh, MN, Hb-A, LDH-A, LDH-B, SOD, PGM-1, PGM-2, 6PGD, GPT, ESD, ADA, ACP, PGK, MDH, Alb, Hp, and Tf) determined from 310 blood samples collected among the Gainj, a small population of tribal horticulturalists from highland Papua New Guniea. Fourteen of these loci display genetic variants, and ten of them are sufficiently polymorphic to permit a preliminary analysis of Gainj population structure. Patterns of variation among subdivisions of the population are analyzed using an approach analogous to a multivariate analysis of variance with unbalanced design, and weighted genetic distances are extracted from the results. The distance analysis indicates that patterns of genetic variation within this population reflect the geographical distribution of subdivisions, as well as subdivision size and movement among subdivisions. A parallel analysis of the Gainj and two other tribal groups from highland New Guinea, the Murapin Enga and the Simbai Valley Maring, suggests that the Gainj are both genetically divergent from neighboring populations and internally highly differentiated.

Jk(a-b-) red blood cells resist urea lysis

Falsely high automated platelet counts in a patient with aplastic anemia were found to be due to increased resistance of the red blood cells to urea lysis. The patient's blood group Jk(a-b-). Further investigation revealed that this phenomenon occurred with all of eight bloods of the phenotype Jk(a-b-) but not with red blood cells of other phenotypes tested. We therefore report an association of a rare blood group phenotype with unusual red blood cell behavior in vitro.

Blood group, red cell enzyme and serum protein types in the Buka Islanders, Papua New Guinea

Genetic marker studies on a sample of 80 speakers of the Petats and Tinputs families of languages, all pupils at a single high school, indicate a homogeneity among them which can be extrapolated to their areas of origin. Buka and its offshore islands and the northern part of Bougainville Island in the North Solomons Province of Papua New Guinea. Several markers systems, most notably first-locus phosphoglucomutase and liver acetyltransferase, reinforce the morphological evidence that these peoples are quite distinct from most other Papua New Guinea populations, with whom, however, there has been some gene exchange, probably through East New Britain. Their principal affinities are with the peoples of the Solomon Islands to the south.