The European Grief Conference, Copenhagen 2022: An effort to unite the field of bereavement care in Europe

Bereavement care in Europe varies in quality and availability. Through greater collaboration across Europe, there could potentially be an opportunity to improve care. This article discusses the inaugural European Grief Conference held in Denmark in 2022: "Bereavement and Grief in Europe - Emerging Perspectives & Collaborations". The conference was structured around a 4-tiered public health model of bereavement care needs. It included practice, research, policy, and educational perspectives. A total of 250 people from 27 different countries participated. To determine if the conference had appealed to a broad European audience of grief professionals and to assess how the conference was received by participants, we examined registration/submission data, the results of a one-word real-time feedback exercise, and the answers to an online satisfaction survey. The results indicated wide interest in greater information sharing and collaboration across Europe among bereavement care, research, and education professionals.

Risk factors for prolonged grief symptoms: A systematic review and meta-analysis

BACKGROUND

The diagnosis Prolonged Grief Disorder (PGD) has recently been included in ICD-11 and DSM-5-TR. To identify individuals who need help coping with grief, knowledge is needed about who is at risk of developing PGD. We, therefore, conducted a comprehensive systematic review and meta-analysis of the available literature on risk factors for prolonged grief symptoms (PGS).

METHODS

Based on a literature search in PsycInfo, PubMed, Web of Science, and CINAHL, we included the most frequently investigated risk factors in a meta-analysis. The effect size correlation was used as the standardized measure of the strength of the association between the risk factor and PGS.

RESULTS

Based on 120 studies of 61.580 participants published between 1989 and 2023, 19 risk factors were included in the meta-analysis. For the adjusted associations, the strongest associations with PGS were pre-loss grief symptoms (ESr = 0.39, 95%CI[0.24-0.53]) and depression (ESr = 0.30, 95%CI[0.13-0.44]). Small, but statistically significant associations were observed for unexpected death, violent/unnatural death, low educational level, low income, female gender, anxious attachment style, and death of a child or partner.

CONCLUSIONS

An updated overview of risk factors for PGS is presented, including their predictive strength. The results offer knowledge that can aid prevention and early identification of people at risk of PGD.

Radiography students' viewpoints of the clinical learning environment: A cross-sectional study

INTRODUCTION

The quality of clinical learning environments (CLEs) impact learners' experience and competence development. Objective instruments have been developed to evaluate CLEs from the perspective of medical and nursing students. No such instruments have been used in Radiography.

METHODS

Radiography students' perspectives of CLEs were investigated using the validated Undergraduate Clinical Education Environment Measure (UCEEM). Undergraduate (UG) (n = 365) and graduate entry (GE) radiography students (n = 45) from an Irish university were invited to participate. CLEs consisted of 25 public and 10 private hospitals. The UCEEM contains 26 items under two overarching dimensions, experiential learning and social participation, with four subscales: opportunities to learn in and through work and quality of supervision; preparedness for student entry; workplace interaction patterns and student inclusion; and equal treatment.

RESULTS

Two hundred and ten students participated (response rate 52.4%; n = 185 UG, n = 30 GE), most of whom were based in public hospitals (87.4%). The mean UCEEM score was 107.5 ± 17.7 (optimal range: 90-125). Experiential learning and social participation were scored 74.2 ± 12.5 (optimal range: 60-85) and 33.37 ± 6.29 (optimal range: 30-40), respectively. Private hospitals ranked slightly higher than public hospitals for 'opportunities to learn in and through work and quality of supervision' (p = 0.018). Items ranked highest related to 'equal treatment' and 'opportunity to put theory into practice'. Clinical supervision-related items were scored highest by first-year students.

CONCLUSION

High UCEEM scores indicate radiography students' positive perceptions of their CLEs, particularly regarding equality and experiential learning. Findings support the expansion of radiography placement to include public and private hospitals.

IMPLICATIONS FOR PRACTICE

The UCEEM is a theoretically robust, validated tool which appears suitable for evaluating radiography CLEs. This study provides valuable baseline data for comparison of Radiography CLEs.

Operationalization, implications and correlates of the cultural deviance criterion for ICD-11 and DSM-5 prolonged grief disorder

Prolonged Grief Disorder (PGD) is included in ICD-11 and DSM-5-TR and includes a requirement of cultural deviance. This study examined endorsement rates and factors associated with endorsement of this criterion among Danish bereaved spouses (n = 425) and their adult children (n = 159) four years post-loss. In total, 7.5% (n = 44) participants endorsed this criterion. Both including and excluding the criterion, the prevalence rates for probable DSM-5-TR PGD were 1.4% (n = 8) and 1.7% (n = 10), respectively and for probable ICD-11 PGD were 1.4% (n = 8) and 2.2% (n = 13), respectively. Age and gender of the deceased, age of the bereaved, greater grief severity, and comorbid psychopathology were positively associated with endorsement of the criterion. Findings demonstrate low endorsement of the cultural deviation criterion, that its inclusion excludes several potential PGD cases, and unanticipated associations with several factors raise questions about the criterion's validity.

Grief is a family affair: examining longitudinal associations between prolonged grief in parents and their adult children using four-wave cross-lagged panel models

BACKGROUND

Losing a parent or spouse in adulthood may result in prolonged grief disorder (PGD) symptoms. PGD levels in parents may affect PGD levels in their adult offspring and the other way around. However, research on transmission of PGD in parent-child dyads is lacking. Consequently, we aimed to examine temporal associations between PGD levels in parent and adult children.

METHODS

In doing so, we analyzed longitudinal self-report data on PGD levels (using the PG-13) assessed at 2, 11, 18, and 26 months after loss in 257 adult parent-child dyads from Denmark. Cross-lagged panel modeling was used for data-analyses.

RESULTS

Changes in PGD levels in parents significantly predicted PGD levels in adult children, but not vice versa. Small through moderate cross-lagged effects (β = 0.05 through 0.07) were found for PGD levels in parents predicting PGD levels in adult children at a subsequent time-point. These cross-lagged effects were found while taking into account the association between PGD levels in parents and adult children at the same time-point as well as the associations between the same construct over time and relevant covariates.

CONCLUSIONS

Pending replication of these findings in clinical samples and younger families, our findings offer tentative support for expanding our focus in research and treatment of PGD from the individual to the family level.

An investigation into academic career pathways across Radiography education centres internationally

INTRODUCTION

Robust academic pathways are critical to support of radiography faculty within third level education. As the profession of Radiography grows its' research activity, it is important that academic opportunities meet the needs of the profession. The purpose of this research was to investigate current academic career pathways across radiography education centres internationally.

METHODS

An online survey was developed and administered to radiography academics and clinical/academic staff members internationally. The survey questions (n = 28) include demographic data; teaching and research requirements; academic promotion criteria; identification of the challenges and benefits of being an academic, including equality, diversity and inclusion (EDI) matters.

RESULTS

A total of 175 responses were obtained (6 continents and 39 countries), with a variety of experience levels amongst academics that primarily held permanent work contracts. Regarding the highest qualifications held, 31.4% (n = 55) had a Doctorate and 45.7% (n = 80) a Master's degree, and most respondents were employed as academic lecturers (40.6%; n = 71), with 17.7% (n = 31) employed at professorial level. The minimum time requirement to achieve a permanent contract was variable, ranging from no delay (5.7%; n = 10) to more than 10 years (12.6%; n = 22). Doctorate qualification is currently not necessary in order to career progression for 126 (72%) respondents, while 52% (n = 91) provided specific research requirements. 106 (60.6%) respondents indicated that their institution has EDI policy.

CONCLUSION

This study has captured details related to academic pathways across international radiography education centres. Whilst some heterogeneity exists, there are numerous differences impacting standardised academic career opportunities for Radiography academics. These may challenge academic career opportunities and discourage those interested in an academic career.

IMPLICATIONS FOR PRACTICE

The profile and educational background of these academics has been highlighted as well as the perceived barriers and advantages of a career in academic.

Radiographers' experiences and educational needs in relation to caring for suicidal patients during radiology examinations

INTRODUCTION

Researchers have explored the experiences, attitudes, and educational needs of several healthcare professional groups in relation to caring for suicidal patients. However, radiographers have not been included in these studies. Radiographers are likely to encounter these patients when they present for diagnostic imaging following suicide attempts.

METHODS

An online questionnaire exploring radiographers' experiences and educational needs in caring for suicidal patients was circulated to radiographers working in 23 acute hospitals across Ireland and posted to a Facebook page targeting Irish-based radiographers. Closed-ended questions were used to capture respondents' demographics and five-point Likert scale questions to establish their confidence levels in imaging suicidal patients. Open-ended questions were used to explore their experiences and educational needs. Quantitative data was analysed using descriptives statistics, and qualitative data thematically analysed.

RESULTS

One hundred and four radiographers responded to the questionnaire, 96% of whom had imaged suicidal patients. Radiographers were confident in justifying and optimising these radiographic examinations, however, less confident in communicating with and caring for these patients. Radiographers reported insufficient patient history on imaging referrals and challenges in communicating with suicidal patients, which many attributed to lack of training. Radiographers expressed interest in further education related to caring for patients who've attempted suicide, which they felt should include an introduction to psychiatry, strategies for communicating with suicidal patients and building resilience.

CONCLUSION

Radiographers' experiences of imaging suicidal patients have been reported along with several challenges which could be addressed through further education.

IMPLICATIONS FOR PRACTICE

Further education in caring for suicidal patients should be offered to radiographers which aligns with their educational needs. Referring clinicians should be reminded of the importance of informing radiographers of patients' suicide attempt when referring them for diagnostic imaging.

Radiographers' organisational commitment and occupational stress: First Covid-19 wave

INTRODUCTION

Radiographers, like many health professionals, are in a high-risk group for succumbing to workplace demands beyond their ability to cope, particularly in the context of the COVID-19 pandemic resulting in occupational stress. Occupational stress has been linked to poor organisational commitment. Therefore, the purpose of this research was to evaluate radiographers' organisational commitment and occupational stress after the first wave of the COVID-19 pandemic.

METHODS

A mixed method approach entailed data collected from purposively sampled Australian radiographers working during the first COVID-19 wave. The quantitative phase used an online commitment questionnaire, and 21 semi-structured individual virtual interviews were conducted in the qualitative phase. Data interpretation and analysis used statistical and thematic approaches.

RESULTS

The quantitative data revealed a higher level of continuance than affective and normative commitment. Whereas the qualitative findings showed participants high levels of affective commitment to their occupation and, together with leadership support, working collectively towards a positive outcome.

CONCLUSION

Despite the variety of occupational stressors that arose during the COVID-19 crisis, Australian radiographers enjoy a high level of occupational and organisational commitment.

IMPLICATIONS FOR PRACTICE

Radiographers' organisational commitment represents their emotional and psychological attachment to their workplace, and radiographers experiencing occupational stress represent high levels of psychosomatic distress and burnout. Therefore, considering radiographers' organisational commitment and occupational stress is essential in the delivery of services, quality of patient care and radiographers well-being.

Student perceptions of the use of three-dimensional (3-D) virtual reality (VR) simulation in the delivery of radiation protection training for radiography and medical students

BACKGROUND

VR simulation-based learning is increasingly used in healthcare education to prepare students for clinical practice. This study investigates healthcare students' experience of learning radiation safety in a simulated interventional radiology (IR) suite.

METHOD

Radiography students (n = 35) and medical students (n = 100) were introduced to 3D VR radiation dosimetry software designed to improve the learners' understanding of radiation safety in IR. Radiography students underwent formal VR training and assessment, which was complemented with clinical placement. Medical students practiced similar 3D VR activities informally without assessment. An online questionnaire containing Likert questions and open-ended questions was used to gather student feedback on the perceived value of VR-based radiation safety education. Descriptive statistics and Mann-Whitney U tests were used to analyse Likert-questions. Open-ended question responses were thematically analysed.

RESULTS

A survey response rate of 49% (n = 49) and 77% (n = 27) was obtained from radiography and medical students respectively. Most respondents (80%) enjoyed their 3D VR learning experience, favouring the in-person VR experience to online VR. 73% felt that VR learning enhanced their confidence across all relevant learning outcomes. Whilst confidence was enhanced across both cohorts, VR learning had a greater impact on confidence levels amongst medical students with respect to their understanding of radiation safety matters (U = 375.5, p < 0.01). 3D VR was deemed a valuable assessment tool.

CONCLUSION

Radiation dosimetry simulation-based learning in the 3D VR IR suite is perceived to be a valuable pedagogical tool by radiography and medical students and enhances curricula content.

Recruitment and retention of radiography clinical practice educators

INTRODUCTION

Clinical Practice Educators (CPEs) play a vital role in radiography education, fostering the development of students' clinical competence and creating positive learning experiences. In recent years, there has been a high turnover and difficulties recruiting radiography CPEs in Ireland. This is the first study to explore issues surrounding recruitment and retention of radiography CPEs.

METHOD

A cross-sectional, mixed-method study was conducted to gain a better understanding of the issues surrounding recruitment and retention of radiography CPEs. Current and former CPEs affiliated with undergraduate radiography training in Ireland were recruited. CPEs completed an online questionnaire detailing demographics and career background. Online semi-structured focus groups were conducted with current CPEs and interviews with former CPEs.

RESULTS

Nineteen current CPEs completed the questionnaire and participated in focus groups (95% response rate). Ten CPEs who had resigned within the last five years were interviewed. The main motivators for CPEs were an interest in teaching, inspiration from role models, personal learning goals and the appeal of part-time employment. Job satisfaction was influenced by efficacy in the role, professional growth, autonomy, and relationships with stakeholders. The main disincentives were the CPE grade not being commensurate with work involved, lack of protected time and lack of support from colleagues. A variety of reasons for resignation were provided, many of which related to grading of the CPE post and lack of career progression opportunities in the role.

CONCLUSION

The findings outline the key motivators for radiography CPEs and disincentives relative to recruitment and retention of radiography CPEs in Ireland.

IMPLICATIONS FOR PRACTICE

By understanding the disincentives relative to CPE recruitment and retention, along with the motivators, employers can devise initiatives that reduce turnover and increase CPE retention.

Clinical portfolios as a tool to develop competence in radiography education

INTRODUCTION

Clinical portfolios are used in healthcare programmes to prepare students for their professional careers by promoting reflective practice and critical thinking. There is a paucity of research related to students' and educators' perceptions of the effectiveness of clinical portfolios in radiography education.

METHODS

A cross-sectional, questionnaire-based study was conducted to explore radiography students' and educators' opinions on the contribution of portfolios to students' personal and professional development. Optimal portfolio content and administration was investigated. Questionnaires were distributed to a stratified sample of second-, third- and fourth-year undergraduate radiography students and recent graduates from a 4-year BSc Radiography program in Ireland. A second questionnaire was sent to academic staff involved in clinical education. Participation was on a voluntary basis and data anonymous.

RESULTS

Sixty participants provided the student perspective and seven provided the educator perspective. All educators and most radiography students (58-83%) agreed that the portfolio contributed effectively to personal and professional development. Tutor feedback and competency assessments were ranked the most valuable elements of the portfolio by both students and educators. The remainder content ranked from most to least beneficial were; image appraisal assignments, self-reflection, training needs analysis and modality objective lists. Final-year students and new graduates valued self-reflections more than novice students. Online portfolio administration was preferred over paper administration (5:3) due to greater efficiency, accessibility, and interactivity.

CONCLUSION

The clinical portfolio was perceived to be an effective tool for developing competence in radiography education. Study findings may be used to optimise radiography clinical portfolio design and administration.

IMPLICATIONS FOR PRACTICE

This study is the first to highlight elements of a clinical portfolio deemed most effective in competence development from the perspective of radiography students and educators.

An exploration of gender and prolonged grief symptoms using network analysis

BACKGROUND

Gender has been proposed as a potentially important predictor of bereavement outcomes. The majority of research in the field has explored this issue by examining gender differences in global grief severity. Findings have been mixed. In this study, we explore potential gender differences in grief using network analysis. This approach examines how individual symptoms relate to and reinforce each other, and so offers potential to shed light on novel aspects of grief expression across genders.

METHOD

Graphical lasso networks were constructed using self-report data from 839 spousally bereaved older participants (584 female, 255 male) collected at 2- and 11- months post-bereavement. Edge strength, node strength and global network strength were compared to identify similarities and differences between gender networks across time.

RESULTS

At both time points, the strongest connection for both genders was from yearning to pangs of grief. Yearning, pangs of grief, acceptance, bitterness and shock were prominent nodes at time 1. Numbness and meaninglessness emerged as prominent nodes at time 2. Males and females differed in the relative importance of shock at time 1, and the female network had greater overall strength than the male network at time 2.

CONCLUSIONS

This study identified many similarities and few differences in the relationships between prolonged grief symptoms for males and females. Findings suggest that future studies should examine alternate sources of variation in grief outcomes. Limitations are discussed.

A qualitative analysis of radiography students' reflective essays regarding their experience of clinical placement during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic significantly impacted healthcare services and clinical placement for healthcare students. There is a paucity of qualitative research into radiography students' experiences of clinical placement during the pandemic.

METHOD

Students in stages three and four of a 4-year BSc Radiography degree in Ireland wrote reflective essays regarding their experience of clinical placement during the COVID-19 healthcare crisis. Permission was granted by 108 radiography students and recent graduates for their reflections to be analysed as part of this study. A thematic approach to data analysis was used, allowing themes to emerge from the reflective essays. Two researchers independently coded each reflective essay using the Braun and Clarke model.

RESULTS

Four themes were highlighted; 1) Challenges associated with undertaking clinical placement during the pandemic, such as reduced patient throughput and PPE-related communication barriers; 2) Benefits of clinical placement during the pandemic, in terms of personal and professional development and completing degree requirements to graduate without delay; 3) Emotional impact and 4) Supporting students in clinical practice. Students recognised their resilience and felt proud of their contribution during this healthcare crisis but feared transmitting COVID-19 to family. Educational and emotional support provided by tutors, clinical staff and the university was deemed essential by students during this placement.

CONCLUSIONS

Despite the pressure hospitals were under during the pandemic, students had positive clinical placement experiences and perceived these experiences to have contributed to their professional and personal growth.

IMPLICATIONS FOR PRACTICE

This study supports the argument for clinical placements to continue throughout healthcare crisis periods, albeit with additional learning and emotional support in place. Clinical placement experiences during the pandemic prompted a deep sense of pride amongst radiography students in their profession and contributed to the development of professional identity.

Supporting radiography clinical placements in Ireland during the COVID-19 pandemic: The practice educators perspective

INTRODUCTION

The COVID-19 pandemic has significantly impacted healthcare services and the clinical learning environment. Several studies have investigated radiography students' experiences of clinical placement during the pandemic; however, few have investigated the Clinical Practice Educator's (CPEs) perspective. CPEs play a pivotal role in supporting clinical education.

METHOD

A qualitative study was conducted using a purposeful sample of twenty-two CPEs, each working in a different Irish hospital. Four semi-structured focus groups were used to gather data. To maintain reasonable homogeneity, CPEs who were new to the role (n = 8) were assigned a separate focus group from experienced CPEs (n = 14). Inductive thematic analysis was applied.

RESULTS

CPEs experienced role expansion, particularly in managerial and administrative aspects of the role. They described arranging COVID-19 vaccinations locally for radiography students and the complexities of student rostering during the pandemic. CPEs perceived the pandemic to have impacted students' emotional wellbeing with 'high anxiety levels' and 'loneliness' being reported. They also perceived issues with clinical readiness and the student transition to clinical practice. Many challenges were faced by CPEs including arranging clinical recovery time for numerous students when sites were already at full capacity, fewer learning opportunities due to decreased patient throughput and range of imaging examinations, social distancing constraints, resistance from staff to student placements, and a shortage of staff for student supervision. Flexibility, communication, and multi-level support helped CPEs to fulfil their role.

CONCLUSION

The results provide insight into how CPEs supported radiography clinical placements during the pandemic and into the challenges faced by CPEs in their role. CPEs supported student placement through multi-level communication, teamwork, flexibility, and student advocacy.

IMPLICATIONS FOR PRACTICE

This will aid understanding of the support mechanisms needed by CPEs to provide quality clinical placements.

The impact of 3D virtual reality radiography practice on student performance in clinical practice

INTRODUCTION

Simulation-based learning plays an integral role in preparing students for clinical practice. This study investigated the impact of immersive three-dimensional (3D) virtual reality (VR) simulation-based learning on first-year radiography students' performance in the clinical setting.

METHODS

A retrospective analysis of first-year radiography clinical assessments was carried out to compare performance pre-and post-introduction of VR. The stage one cohort with no VR education was considered the control group (n = 93). The VR group (n = 98) had seven hours of practice in the immersive VR suite (Virtual Medical Coaching). Experienced clinical tutors assessed first-year students performing an extremity radiographic examination in the clinical setting. Assessment criteria were ranked on a 5-point Likert scale from poor to excellent. Mann Whitney U Tests were applied to compare performance across cohorts.

RESULTS

Students trained with VR performed better across 20 of the 22 assessment criteria. VR-trained students performed significantly better (more ranked as 'very good' or 'excellent') than the control group in the following criteria; positioning patients for X-rays (19% difference) (U = 3525, z = -2.66, p < 0.05), selecting exposure factors (12% difference) (U = 3680, z = -3.13, p < 0.05), image appraisal of patient positioning (27% difference) (U = 3448, z = -2.9, p < 0.05) and image appraisal of image quality (18% difference) (U = 3514, z = -2.6, p < 0.05). Their comprehension of clinical indications, equipment set up and explanation of the procedure was also significantly better (p < 0.05).

CONCLUSION

This is the first study to investigate the translation of VR learning into radiography clinical practice. VR learning had a positive impact on the performance of first-year students in their clinical assessment, especially with respect to patient positioning, exposure parameter selection and image appraisal.

IMPLICATIONS FOR PRACTICE

VR is a valuable educational tool in preparing novice radiography students for clinical practice. It is particularly useful to enhance student knowledge in the areas of patient positioning, exposure factor selection and radiographic image appraisal.

Healthcare workers' experiences of caring for patients colonized with carbapenemase-producing Enterobacterales (CPE) in an acute hospital setting - a scoping review

Carbapenemase-producing Enterobacterales (CPE) is an increasing public health concern; these bacteria are highly transmissible in hospital environments and the number of patients with these multidrug-resistant bacteria is rising. Healthcare workers caring for patients colonized with CPE offer insight into care delivery and processes in the hospital setting. The aim of this review was to explore healthcare workers' experiences of caring for patients colonized with CPE. A scoping review method was employed and seven electronic databases (CINAHL, Academic Search Complete, Cochrane, Embase, Medline, Web of Science and Scopus) and four grey literature databases (Open Grey, Grey Literature Report, Clinical trials. gov and WHO International Clinical Trials Registry Platform) were searched using specific search terms and inclusion/exclusion criteria. A PRISMA flow diagram was used to illustrate the process of article selection and thematic analysis used to form themes. Three studies met the criteria to be included in this review. Two main themes were identified from analysing the articles: 'Safeguarding' and 'Power of Knowledge'. The desire to protect themselves, their families and patients was evident from the studies. Healthcare workers were aware of the importance on infection prevention and control measures such as hand hygiene, in preventing the transmission of CPE, however barriers to these were identified, such as time constraints. In conclusion, healthcare workers have negative associations when it comes to caring for patients with CPE. Very little research has been conducted in the area and there is an opportunity to further explore the experience of healthcare workers caring for patients with CPE to identify opportunities for improvement and support of staff.

309 A FRAILTY CENSUS OF INPATIENTS AGED 65 AND OVER ADMITTED TO A MODEL 4 HOSPITAL

Background

Frailty is a risk factor for in-hospital mortality, long hospital stay and functional decline at discharge. Profiling the prevalence and level of frailty within the acute hospital setting is vital to ensure evidence-based practice and service development within the construct of frailty.

Methods

All patients aged ≥65 years and admitted to a medical or surgical inpatient setting, were screened over a 12-hour period (08:00-20:00) using validated frailty and co-morbidity scales. Age and Gender Demographics, Clinical Frailty Scale (CFS), Charlson Co-morbidity Index (CHI) and admitting specialty (Medical/Surgical) were collected. The data was fully anonymised and ethical approval was granted. Descriptive statistics were used to profile the cohort and Chi-squared tests applied for comparisons.

Results

Within a sample of 413 patients, 291(70%) were ≥65yrs. Of this cohort, 202(70%) were ≥75yrs. 207(71%) utilised in-patient medical services and 121(41%) surgical services while 37(12%) used both. The mean CFS was 6 indicating moderate frailty levels and the mean CCI score was 4 denoting moderate co-morbidity. Overall: 195(67%) had moderate-severe frailty (CSF ≥6) while 218 (75%) had moderate-severe co-morbidity (CCI Mod 3-4, Severe ≥5). Associations with age &gt;75 and frailty (p=0.001) and medical service usage and frailty (p=0.004) were established. No significant differences were observed across genders for CFS (p=0.110) and CCI (p=0.465).

Conclusion

There is a high prevalence of frailty and co-morbidity within the admitted patient cohort ≥65yrs. Overcrowding across the hospital system and higher levels of frailty and comorbidity will contribute to increased lengths of stay and the need for specialist intervention, particularly for those ≥75yrs who represented 70% of patients screened. With an increased focus on the integration of care for older adults across care transitions, there is a clear need for expansion of frailty-based services and staff training in frailty care across the hospital and community setting.

299 OLDER PERSONS’ EXPERIENCES AND PERSPECTIVES OF COMPREHENSIVE GERIATRIC ASSESSMENT

Background

There is an abundance of evidence to demonstrate the positive impacts of Comprehensive Geriatric Assessment (CGA) on clinical and process outcomes for older adults across settings of care. However, it is unclear how older adults themselves view CGA and their experiences of the care process. The aim of this qualitative evidence synthesis is to explore the experiences and perspectives of older adults of CGA.

Methods

A comprehensive literature search was completed across MEDLINE, CINAHL, PsycINFO, PsycARTICLES and Social Sciences Full Text. Qualitative or mixed methods studies that included qualitative data on the perspectives and experiences of older adults of CGA were included. The methodological quality of the included studies was appraised using the Critical Appraisal Skills Programme checklist for qualitative research. Findings were synthesised using thematic analysis

Results

Nine studies were included in the synthesis, including studies where CGA was completed in hospital, outpatient assessment unit and home settings. Divergent experiences of CGA were reported. Older adults reported experiences of being respected and listened to during CGA and attention paid to all their issues and priorities. Good communication by healthcare providers was central to these positive experiences (theme 1). In contrast, experiences of being unclear about the aim of CGA or perceived benefits of CGA, feeling that the outcome of CGA did not align with their priorities (theme 2) and not feeling involved in decision making during CGA (theme 3) were also commonly reported.

Conclusion

Findings indicate that CGA is a process by which older adults can felt respected and paid attention to. However, scope exists to further improve older adults’ experiences of CGA. Enhanced healthcare provider communication and facilitation of older adult involvement in decision-making are priority areas for improvement. Further research should focus on exploring other stakeholder groups experiences of CGA including caregivers and healthcare professionals.

95 EXPLORING HIP FRACTURE OUTCOMES IN POST-ACUTE REHABILITATION: A MULTI-SITE AUDIT

Background

In 2020, 28% of all hip fractures in Ireland were discharged to off-site rehabilitation. The annual Irish Hip Fracture Database (IHFD) report captures patient outcomes at the point of acute discharge however patient outcomes at discharge from offsite rehabilitation are unknown.

Methods

A multi-site retrospective audit was completed examining hip fracture outcomes for patients admitted to four post-acute rehabilitation hospitals during 2021, using IHFD HIPE portals as well as local databases. Descriptive statistics including demographics, pre-fracture mobility as well as outcomes measured including acute length of stay, rehabilitation length of stay, discharge destination and independence with mobility on discharge from rehabilitation. A comparison analysis between sites was completed.

Results

A total of 445 patients were admitted post hip fracture to the four rehabilitation hospitals in 2021. Most were female (69%, n=307), mean age 82.5, 49% lived alone and most (55%) had low pre-fracture mobility as measured by New Mobility Score of 0-6. The mean acute length of stay was 11.8 days and rehabilitation stay 37.6 days. Most (90.2% of complete data, n=333) discharged home, 4.5% (n=17) were transferred to hospital, 3.2% (n=12) were newly admitted to nursing home and 1% (n=4) died. Most (82.2% of complete data, n=256) were independently mobile (CAS 6) at discharge from rehabilitation. There was no significant difference in patient profile between sites however there were significant difference in both acute length of stay (median range 8-13days) as well as rehabilitation length of stay (median range 16-39days).

Conclusion

The findings of this audit provide a new perspective on recovery post hip fracture and insight into longer term hip fracture outcomes. It shows that data collection is feasible in off-site rehabilitation units and should be considered for inclusion in the IHFD. Further work could explore the establishment of standards of care in the post-acute phase of hip fracture rehabilitation.

331 THE USE OF BODY MASS INDEX IN PREDICTING ORTHOSTATIC HYPOTENSION IN OLDER ADULTS

Background

The presence of Orthostatic Hypotension (OH) is known to be associated with an increased mortality risk. Previous Irish research has shown that elevated Body Mass Index (BMI) may be protective against OH, with overweight and obese patients having significantly smaller Systolic Blood Pressure (SBP) drops during Head-Up-Tilt (HUT) Testing.

Methods

Demographics, including age, height and weight, were obtained retrospectively from all head up tilt testing performed in a tertiary Irish hospital between 2000 and 2021. All incomplete records were excluded. A total of 4,717 patients were analysed. Linear regression models were used to examine the relationship between BMI and change in tilt SBP.

Results

2,089 males and 2,628 females over the age of 60 years old were examined. The mean age is 77 years ± 7.8 (S.D.), with majority (51.5%) of the cohort overweight or obese. 69.7% of individuals demonstrated OH. The mean change in tilt SBP was –7mmHg in the underweight and healthy weight group, and –10mmHg in the overweight or obese group. The linear regression model established that BMI significantly predicted a change in tilt SBP (beta=0.394, 95% CI: 0.235 to 0.554, p&lt;0.001), but remains a poor predictive variable (R2=0.004) for this cohort. This correlation was similar for both genders (male: r=0.08, female: r=0.07).

Conclusion

Our findings confirmed a correlation between BMI and its predictive impact on OH in older adults. Future studies should explore targeted populations with multivariate analysis, taking into consideration age and gender, to reduce the heterogeneity of data.

320 IDENTIFYING OUTCOMES FOR PATIENTS LEAVING REHABILITATION WITHOUT THE MULTI-DISCIPLINARY TEAM (MDT) RECOMMENDED HOME CARE PACKAGE (HCP) HOURS IN PLACE

Background

Home-Care Packages (HCPs) aim to support older people to remain in their homes. The community care system in Ireland has a small range of services with inconsistent availability. This study aims to identify outcomes for patients leaving rehabilitation without the MDT recommended HCP.

Methods

Demographics of patients discharged from rehab January 2021 to December 2021 were collected. Patients were classified into those with and without recommended HCP at time of discharge. Telephone consultations were held and data collected including; number of falls since discharge and EQ-ED-5L quality of life questionnaires were completed.

Results

Of 30 patients included (aged 66-94), 9 did not have full HCP hours on discharge. The range of Length of Stay (LoS) was 2-120 days in the correct HCP group and 7-59 in the incorrect HCP group. There was 7 readmissions to hospital, 5 from full HCP group. Three patients had a fall since discharge. In the correct HCP group, 42% had a mobility score of 3 or greater and 38% had a self-care score of 3 or greater. This was 11% and 33% respectfully in the incorrect HCP group.

Conclusion

Those who were discharged with full HCP had larger range of LoS. All patients who suffered falls were in the full HCP group. Incorrect HCP group had better scores in mobility and self-care. There were low rates of readmission to hospital in this group of patients discharged following a period of rehabilitation.

303 SCREENING INSTRUMENTS TO PREDICT ADVERSE OUTCOMES FOR UNDIFFERENTIATED OLDER ADULTS ATTENDING THE EMERGENCY DEPARTMENT: RESULTS OF SOAED PROSPECTIVE COHORT STUDY

Background

Frailty screening facilitates the stratification of older adults at most risk of adverse events for urgent assessment and subsequent intervention in the acute or community setting. We assessed the validity of the ISAR (Identification of Seniors at Risk), Rockwood Clinical Frailty Scale (CFS), PRISMA-7 and InterRAI-ED at predicting adverse outcomes at 30 days and six months among older adults presenting to the ED.

Methods

A prospective cohort study of consecutive older adults (≥65 years) who presented to the ED at a University Hospital was conducted. The ISAR, CFS, PRISMA-7 and InterRAI-ED were performed by an experienced ED research nurse. Blinded follow-up telephone interviews were completed at 30 days and six months to assess the incidence of mortality, ED re-attendance, hospital readmission, functional decline and nursing home admission. The sensitivity and specificity of the screening tools were calculated using 2×2 tables.

Results

419 patients were recruited with 49% female and a mean age of 76.9 years (SD 7.15). The prevalence of frailty varied across the screening tools (ISAR, 47% vs InterRAI-ED, 63%). At 30-days, mortality rate was 5.4%, ED re-attendance 16.9%, hospital readmission 13.6%, functional decline 47.1% and nursing home admission 7.3%. Older adults who screened positive for frailty demonstrated an increased risk of all adverse outcomes at 30 days and 6 months, regardless of frailty screening tool administered. All tools had a relatively high sensitivity but low specificity. The ISAR was the only tool which was statistically significant at predicting all outcomes at 30 days.

Conclusion

The ISAR, CFS, PRISMA-7 and InterRAI-ED demonstrated modest validity at predicting adverse outcomes at 30 days and 6 months. We would recommend the implementation of one of these frailty screening tools in Irish EDs to support clinicians in identifying older adults most likely to benefit from specialised geriatric assessment and intervention in the hospital or community setting.

220 RELATIONSHIP BETWEEN HEIGHT AND SYSTOLIC BLOOD PRESSURE IN OLDER ADULTS

Background

Hypertension is common amongst older adults in Ireland and is a major risk factor for both ischaemic and haemorrhagic stroke. Several studies have investigated the relationship between height and hypertension, however results have been inconsistent. In our Irish tertiary hospital patients undergoing tilt table testing have resting blood pressure measured prior to the test, and height recorded. Our aim was to assess whether there is a relationship between height and resting Systolic Blood Pressure (SBP) in patients aged over 60 years.

Methods

All tilt table test results between 2000 and 2021 in a single centre were reviewed retrospectively, collecting data on age, height and resting SBP. Any incomplete records were excluded, as were those from patients under 60 years old. Linear regression modelling was used to assess relationship between height and resting SBP.

Results

A total of 4,729 complete records were included for patients over 60 years old. 2630 (61.5%) of the patients were female. Mean age was 77 ± 7.8 years. 57.7% patients had either an elevated resting systolic and/or diastolic BP ≥130/80 and 28.4% ≥140/90. The linear regression model established that while height could be used to predict resting systolic blood pressure (beta=-0.166, 95% CI: –0.219 to –0.113, p&lt;0.001), height only accounted for 0.8% of variability in resting SBP (R2 = 0.008).

Conclusion

Our large dataset establishes an association but no meaningful causation between height and resting systolic blood pressure. Current antihypertensive treatment was not recorded, which may have affected the results. Future studies will include further multivariate analysis accounting for antihypertensive use and other factors that may impact hypertension such as age, weight and gender.

265 A PHYSIOTHERAPY-LED TRANSITION TO HOME INTERVENTION FOR OLDER ADULTS FOLLOWING EMERGENCY DEPARTMENT DISCHARGE: A PILOT FEASIBILITY RANDOMISED-CONTROLLED TRIAL

Background

Older adults frequently attend the Emergency Department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. A presentation to an ED can be viewed as an opportunity to assess those at risk of adverse outcomes and initiate a care plan in those deemed as ‘high risk'. Our aim was to evaluate the feasibility of a physiotherapy led integrated care intervention for older adults discharged from the ED (ED-PLUS).

Methods

Older adults presenting to the ED with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED-PLUS (Trial registration: NCT04983602). ED-PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient’s own home. Feasibility (recruitment and retention rates) and acceptability of the programme were assessed quantitatively and qualitatively. Functional decline was examined post-intervention using the Barthel Index. All outcomes were assessed by a research nurse blinded to group allocation.

Results

29 participants were recruited, indicating 97% of our recruitment target. 90% of participants completed the ED-PLUS intervention. All participants expressed positive feedback about the intervention. The incidence of functional decline at 6 weeks was 10% in the ED-PLUS group versus 70-89% in the usual care and CGA-only groups.

Conclusion

High adherence and retention rates were observed among participants and preliminary findings indicate a lower incidence of functional decline in the ED-PLUS group. Recruitment challenges existed in the context of COVID-19. Data collection is ongoing for six-month outcomes.

353 FACTORS ASSOCIATED WITH ADVERSE OUTCOMES IN OLDER ADULTS DIRECTLY DISCHARGED FROM THE EMERGENCY DEPARTMENT

Background

Older adults attend the Emergency Department (ED) frequently. Over 40% are directly discharged from the ED. The risk of adverse outcomes is high following discharge including unplanned ED return, institutionalisation, and mortality. The purpose of this study was to highlight factors that predict these adverse outcomes.

Methods

A secondary analysis was completed of SOAED (a prospective cohort study examining screening instruments to predict adverse outcomes for undifferentiated older adults attending the ED) and OPTIMEND (randomised control trial examining the effectiveness of an intervention by a team of Health and Social Care Professionals along with usual care and compared this to standard ED care alone). Inclusion criteria were adults aged 65 years and over presenting to ED at a University Teaching Hospital with medical complaints and a Manchester Triage System category 2–5.

Results

Three-hundred and nine patients were discharged directly from ED (mean age 80 years; 58% female). 96 patients re-attended ED within 6 months. 66 patients were re-hospitalised within 6 months. 16 patients died within six months of discharge. 63% of the discharged patients screened positive for frailty measured by PRISMA-7 (3 or more). Relative risk ratio analysis confirmed that the risk of revisiting a hospital was 1.241 times for patients that scored frail compared to those who scored not frail. The risk of mortality was 1.075 times for patients that scored frail compared to those who scored not frail. The risk of being admitted to a nursing home was 1.146 times for patients that scored frail compared to those who scored not frail.

Conclusion

Older people have a high ED re-attendance rate of 31% after an index visit. Frailty (scored on PRISMA-7) is a significant predictor of adverse outcomes. Focused screening and intervention for frail patients who attend the ED should be a priority.

Evaluation of the Dose-Dependent Inflammatory Response and No-Observable Adverse Effect Level of Intravitreal Endotoxin in the African Green Monkey

Purpose

To evaluate the inflammatory effects and no-observed adverse effect level (NOAEL) of intravitreal endotoxin in an African green monkey model of uveitis.

Methods

Fifteen green monkeys were administered intravitreal endotoxin ranging from 0.005 to 0.08 endotoxin unit (EU)/eye. Inflammation was evaluated by slit-lamp biomicroscopy, indirect fundoscopy, tonometry, color fundus photography, ocular coherence tomography, laser flare photometry, and histopathology, with analysis of cytokine levels in aqueous and vitreous humor. The inter-rater reliability of a refined nonhuman primate ophthalmic scoring system was evaluated.

Results

A dose-dependent inflammatory response was observed beginning at 0.02 EU/eye; no inflammatory response exceeding the vehicle was observed at 0.005 EU/eye. Retinal pathology was minimal, and posterior visualization degraded with increasing inflammation. Inflammation was observed by histopathology at 0.04 EU/eye. Inter-rater reliability of the scoring system was high, with 99.2% of individual scores differing by 1 scale unit or less and 87.2% of summary scores differing by 2 scale units or less.

Conclusions

The NOAEL for intravitreal endotoxin in the green monkey is 0.005 EU/eye, with inflammation increasing with increasing dose beginning at 0.02 EU/eye. This updated nonhuman primate ophthalmic scoring system allows for high inter-rater reliability for the quantification of mild to severe inflammation in the green monkey eye.

Translational Relevance

Validation of the ophthalmic inflammation scoring system enables application of the green monkey as a valuable translational model. Candidate therapeutics should be confirmed to have endotoxin levels below this threshold before safety testing in this species to enable interpretation of inflammation and minimize impact on animal welfare.

941 EFFECTIVENESS OF ACUTE GERIATRIC UNIT CARE AMONG HOSPITALISED OLDER ADULTS WITH ACUTE MEDICAL COMPLAINTS: A META-ANALYSIS

Introduction

Older adults are clinically heterogeneous and are at increased risk of adverse outcomes during hospitalisation due to the presence of multiple comorbid and complex conditions. This systematic review and meta-analysis aims to update and synthesise the totality of research evidence on the effectiveness of acute geriatric unit (AGU) care for older adults admitted to hospital with acute medical complaints.

Method

MEDLINE, CINAHL, CENTRAL, and Embase databases were systematically searched from 2008 to February 2021. Screening, data extraction, and quality grading were undertaken by two reviewers. Only trials with a randomised design comparing AGU care and conventional care units were included. Meta-analyses were performed in Review Manager 5.4 and the Grading of Recommendations, Assessment, Development and Evaluations framework was used to assess the certainty of evidence for outcomes reported. The primary outcome measure was incidence of functional decline between baseline two-week prehospital admission status and discharge and at follow-up.

Results

11 trials recruiting 7,496 participants across three countries were included. AGU care was associated with a 23% reduction in functional decline at six-month follow-up (risk ratio (RR) 0.77, 95% confidence interval (CI) 0.64–0.92; moderate certainty evidence), and significant cost savings (mean difference (MD) -538.01USD, 95% CI -571.05USD—-504.96USD; low certainty evidence). No differences were found in functional decline at hospital discharge or at three-month follow-up, length of hospital stay, the likelihood of living at home, mortality, hospital readmission, cognitive function, or patient satisfaction with the index admission.

Conclusion

AGU care improves clinical and process outcomes for older adults admitted to hospital with acute medical complaints. Future research should focus on greater inclusion of clinical and patient reported outcome measures including quality of life. Use of such measures may lead to a greater focus on patient-centered care and service provision priorities.

1081 A COMPARISON OF THE ISAR TOOL AND THE CLINICAL FRAILTY SCALE TO PREDICT MORTALITY AND ED REATTENDANCE IN A COHORT OF ED ATTENDER

Background

Frailty Screening is one method by which we can risk stratify older adults to urgent assessment in the Emergency Department. The ISAR (Identification of Seniors at Risk) and Rockwood Clinical Frailty Scale are two frailty screening tools. We assessed the validity of these tools at predicting adverse outcomes for older adults presenting to the Emergency Department.

Method

This was a prospective cohort study. Patients over 65 were recruited, baseline.

demographics were obtained and a research nurse assessed them using both the Clinical Frailty Scale and ISAR. Patients were assessed by telephone interviews at one month and six months. The outcome measures assessed were mortality, ED re-attendance, hospital readmission, functional decline and institutionalisation.

Results

419 patients were recruited. 53.3% (223) were male with a median age of 76 (IQR = 10). The median ISAR and CFS score was 2,5 respectively at baseline. The mortality rate was 5.4% and rate of ED re-attendance was 16.9% at one month. The relative risk of ED re-admission with an ISAR score &gt;/= 2 more was 1.84 (1.12, 3.02) and CFS &gt; 4 was 1.85 (1.08, 3.16). The ISAR tool &gt;/= 2, had a sensitivity of 74.29 (95% CI = 62.44, 83.99) and specificity of 41.18 (95% CI = 35.90, 46.61) when used as a diagnostic tool for ED re-admission at one month. The CFS &gt; 4 had a sensitivity of 71.43 (95% CI = 57.79, 82.70) and specificity of 45.23 (95% CI = 39.33, 51.23) for the same outcome.

Conclusion

The ISAR tool &gt;/= 2 was the more sensitive at predicting ED reattendance at one month in comparison to the Clinical Frailty Scale. We would advocate using this tool in the ED setting to highlight those at greatest risk of adverse outcomes and those most likely to benefit from Comprehensive Geriatric Assessment.

Case Report: Thrombotic-Thrombocytopenic Purpura Following Ipilimumab and Nivolumab Combination Immunotherapy for Metastatic Melanoma

A man in his early 50s presented with small bowel obstruction, requiring emergency laparoscopic small bowel resection for the metastatic melanoma of the jejunum with no identifiable primary lesion. One week after his first treatment with ipilimumab and nivolumab, he presented with diffuse abdominal pain, constipation, and fatigue. A computerized tomography scan did not identify a cause for his symptoms. This was rapidly followed by thrombocytopenia on day 11 and then anemia. He commenced intravenous corticosteroids for a suspected diagnosis of immune-related thrombocytopenia. On day 15, a generalized onset motor seizure occurred, and despite plasmapheresis later that day, the patient died from fatal immune-related thrombotic thrombocytopenic purpura (TTP). This was confirmed with suppressed ADAMTS13 (<5%) testing on day 14. Immune-related TTP is a rare and, in this case, fatal immune- related adverse event. Further studies are required to identify additional immunosuppressive management for immune-related TTP.

Woodland's role in natural flood management: Evidence from catchment studies in Britain and Ireland

Despite the attention currently given to the potential environmental benefits of large-scale forest planting, there is a shortage of clear observational evidence regarding the effects on river flows, and what there is has often been contradictory or inconclusive. This paper presents three independently conducted paired-catchment forestry studies covering 66 station-years of flow measurements in the UK and Ireland. In each case coniferous evergreen trees were removed from one catchment with minimal soil disturbance while the adjoining control catchment was left unchanged. Trees were removed from 20% - 90% of the three experimental basins. Following woodland removal there was an increase in dry weather baseflow at all sites. Baseflows increased by about 8% after tree removal from a quarter of the Hore basin and by 41% for the near-total cut at Howan. But the changes were more complex for peak flows. Tree harvesting increased the smallest and most frequent peak storm flows, indicating that afforestation would lead to the suppression of such events. This was however restricted to events well below the mean annual flood, indicating that the impact of forests upon the largest and most damaging floods is likely to be limited. Whilst a forest cover can be effective in mitigating small and frequent stormflows it should never be assumed to provide protection against major flood events.

Wide awake local anaesthesia no tourniquet: a review of current concepts

BACKGROUND: Wide awake local anaesthesia no tourniquet (WALANT) is a local anaesthetic technique that employs lignocaine combined with adrenaline to maintain a pain-free and bloodless field during surgery on an awake patient, without the use of a tourniquet METHODS: This article is a narrative review of the literature on the use of this mode of anaesthesia in orthopaedic and hand surgery RESULTS: The review summarises the existing research pertaining to WALANT. It discusses the anaesthetic solution constituents, administration technique and applications of WALANT, highlighting the safety profile and benefits to patients and healthcare systems alike CONCLUSION: The WALANT technique is safe, economical, and acceptable to patients. It should form part of the orthopaedic surgeon's armamentarium. Future research should investigate the benefits of intraoperative functional assessment of the awake patient Level of evidence: Level 5

High burnout among the South African orthopaedic community: a cross-sectional study

BACKGROUND: Burnout is epidemic among physicians, with the orthopaedic speciality displaying one of the highest rates of burnout in international studies. The burnout rate of the South African orthopaedic community is unknown. This study aimed to determine the prevalence and causes of burnout, as well as the coping mechanisms and associations with burnout, in South African orthopaedic surgeons and trainees METHODS: We conducted a cross-sectional, secure, online survey of members of the South African Orthopaedic Association. The survey assessed demographic characteristics, workload, professional fulfilment and burnout (utilising the Stanford Professional Fulfilment Index), associated workplace distress conditions, causes of and coping strategies for burnout. A response was not compulsory for any question. Statistical analysis was performed to assess for independent associations with burnout RESULTS: One hundred and fifty-six respondents, with a median age of 46.5 years (interquartile range [IQR] 37-58) participated. Ninety per cent (139 of 155) of respondents were male. Registrars accounted for 17% (27 of 155), while 83% (128 of 155) were qualified specialists. Respondents were in orthopaedic practice for a median of 17 years (IQR 9-28). Sixty per cent (76 of 127) practise in private, 17% (22 of 127) in public and 23% (29 of 127) in both sectors. The overall burnout rate was 72% (113 of 156). Burnout was associated with being the parent of young children and having fewer hours of sleep on call. Registrars were more likely to have burnout than consultants (OR 5.68, 95% CI 1.3-25.2). Gender, practice setting and subspeciality were not associated with burnout. Self-reported causes of burnout that were found to be associated with actual burnout were: 'hours at work', 'lack of free time' and 'work-life imbalance'. No self-reported coping mechanisms were found to be protective in this cohort, but the use of alcohol as a coping mechanism was associated with an increased likelihood of burnout (OR 3.9, 95% CI 1.4-10.7). Respondents felt that the concurrent experience of the COVID pandemic at the time of running the survey reduced their experience of burnout CONCLUSION: The burnout rate in the South African orthopaedic community is 72%. Trainees were found to be particularly vulnerable. There appears to be a need to develop, assess and implement effective system-related initiatives aimed at reducing the burnout rate among orthopaedic surgeons and trainees in South Africa Level of evidence: Level 4

233 BISPHOSPHONATES: ANOTHER COMPLEX DRUG TO PRESCRIBE

Background

Bisphosphonates provide effective treatment for osteoporosis. They accumulate a bone reservoir lasting for 3 years and beyond. The 2021 NICE guidelines recommend a medication review and a ‘drug holiday’ after 5 years of oral bisphosphonate therapy for low-fracture risk patients. Continuing treatment for high risk individuals is advised: age=/&gt;75, previous hip or vertebral fracture, one or more fractures during treatment, recent DEXA scan with T score =/&lt;−2.5, and/or current treatment with oral glucocorticoids. This retrospective audit aimed to assess compliance with NICE guidelines in a primary care setting.

Methods

Data were collected using the Health One online medical record system in an urban general practice. Inclusion criteria: all patients =/&gt; 65 years old, prescribed oral bisphosphonate therapy for osteoporosis for &gt;5 years. Exclusion criteria: deceased, did not attend clinic &gt;1 year, patients on bisphosphonate treatment for conditions other than osteoporosis.

Results

137 patients with a history of bisphosphonate therapy were identified. 76 patients were on bisphosphonate treatment for greater than 5 years. Of the 76 patients, 33 were classified as low-fracture risk and appropriately commenced a drug holiday, while 22 correctly remained on bisphosphonates due to a high fracture risk. The remaining 21 patients inappropriately continued therapy without receiving a medication review, repeat DEXA or fracture-risk assessment.

Conclusion

One third of patients on bisphosphonates beyond 5 years were not assessed for a drug holiday. The aim of a bisphosphonate ‘drug holiday’ is to reduce poly-pharmacy and prevent rare but serious long-term adverse events (such as atypical fractures, osteonecrosis of the jaw, gastric cancer and atrial fibrillation). Factors which had an impact on inappropriate prescribing should be assessed. Incorporating computer-based prescribing alerts could support safe prescribing practices.

232 DETECTION OF POST STROKE DEPRESSION IN ACUTE STROKE UNIT AT UNIVERSITY HOSPITAL

Background

Depression is the most common neuropsychiatric manifestation after stroke. It is associated with lower satisfaction and quality of life in stroke survivors and their families. Routine screening for mood disturbance is recommended in stroke patients {Royal College of Physicians, 2016; National Office of Clinical Audit (NOCA) 2019}. The psychological impact of a stroke can present challenges for assessment and diagnosis. We audited the assessment and diagnosis of post stroke depression in a teaching hospital.

Methods

PHQ-9 was prospectively administered to stroke patients (and also to the next of kin with patient consent) within 2 weeks of stroke and repeated at 4–6 weeks after stroke in November 2016. The Patient Health Questionnaire (PHQ—9) is a self-administered, validated screening tool for depression. Chart diagnosis or drug prescribing for depression was retrospectively assessed in the medical and nursing notes.

Results

15 of 34 admitted stroke patients were administered the paper based PHQ-9. 19 patients were excluded due to: severe cognitive impairment; aphasic; death or having been discharged.

No patient had depression diagnosed prior to admission to the hospital. One patient was diagnosed and prescribed an anti-depressant post stroke.

7 patients screened positive for depression on PHQ-9: mild depression n = 4 (27%); moderate n = 2 (13%); and severe depression n = 1 (6%). Repeat questionnaire at 4–6 weeks post stroke revealed an unchanged PHQ-9 score in n = 10 (67%); however n = 2 (11%) had deteriorated and n = 4 (22%) improved.

Conclusion

Depression was a common finding in 47% of patients post stroke and was under-recognized without a formal screening process incorporated in clinical practice. A nuanced screening process, accounting for common co-morbidities such as aphasia and cognitive impairment, was incorporated after this audit. Further guidance is being developed by the National Stroke Programme based on NOCA feedback.

241 IMPLEMENTATION OF AN INTRACEREBRAL CEREBRAL HAEMORRHAGE CARE BUNDLE

Background

Mortality for Intracerebral haemorrhage (ICH) is 31% (Irish National Audit Stroke, 2019). An ICH care bundle focusing on acute anticoagulation reversal, blood pressure lowering, and a neurosurgical care pathway was associated with improved survival. Translating evidence-based medicine into clinical practice is challenging. The aim of this study was to determine feasibility and outcomes of implementation of a care bundle.

Methods

An ICH care bundle was developed using an iterative process involving expert stakeholder review of the evidence-based literature. A pre-and-post quasi-experimental research design was employed to evaluate this intervention. Baseline data were collected before implementation (January 2016-June 2018). Implementation took place in a staged manner in a single university teaching hospital with multiple ‘Plan Do Study Act cycles’ (June 2018 to January 2021). Data on compliance, process measures and outcomes were collected.

Results

Systolic blood pressure (first 24-hours) and anticoagulant reversal were significantly better controlled post-implementation (χ2 (1, N = 91) = 5.34, P = 0.02), (χ2 (1, N = 25) = 5.85, P = 0.016), respectively. DNAR orders were significantly lower in the post-implementation group (χ2 (1, N = 25) = 5.85, P = 0.029). However, ‘Do Not Actively Resuscitate’ status did not significantly differ when accounting for low GCS as a surrogate measure for poor prognosis (χ2 (1, N = 34) = 0.00, P = 0.966). Modified Rankin Scale on discharge did not differ significantly pre-and-post-implementation (z = −0.075, P = 0.94). A greater proportion of patients survived in the post-implementation group; however, this was not statistically significant (χ2 (1, N = 133) = 0.77, P = 0.38). Length of stay significantly increased post implementation.

Conclusion

An ICH care bundle was developed based on expert stakeholder feedback. The feasibility of implementing this bundle of care was demonstrated in a real-world clinical practice setting. A cluster-randomized trial or a large registry study is the next step to evaluate the overall impact of this care bundle on patient outcomes.

249 A SURVEY OF IRISH DOCTORS VIEWS ON FLEXIBLE TRAINING

Background

We aimed to establish the views of non consultant hospital doctors working in Ireland on the options available for ‘Flexible Training’ or ‘Less-Than-Full-Time-Training’. Our population is ageing rapidly, and an expanding workforce will be required. Difficulties with doctor retention and recruitment are growing challenges in Ireland.

Methods

An anonymised survey of 9 questions was carried out using Survey Monkey®. Question format included multiple choice, yes/no or a free text box. This was disseminated via the Royal College of Physicians of Ireland to 1,557 trainees of the Institute of Medicine, the national postgraduate body for medical specialties. It was also circulated to members of the Irish Medical Organisation, the national medical organisation, and to approximately 200 doctors across two hospitals on social media.

Results

There were 674 (84.3%) respondents in training- 46.3% BST, 53.7% HST; and 125 (15.6%) non-training respondents. Doctors overwhelmingly felt trainees should have access to flexible training (n = 849, 99.41%), with 82.39% reporting they would apply (n = 702). Most (92.5%) felt that 16 WTE positions was inadequate (n = 789). Reasons chosen for not applying for flexible training included- 36.1% (n = 169) felt it could impact their career, 25.4% (n = 119) identified they did not meet the criteria, 14.32% (n = 67) reported no interest, while 24.1% (n = 113) gave ‘other’ reasons including lengthy training, salary impacts, and not having a requirement for flexible training. When asked about suggestions for improving flexible training, 19.7% chose ‘offer more places’, 6.7%-‘remove eligibility criteria’, 19.6% -‘offer job sharing options’, 9.5%- ‘allow more flexible training years’, 17.7% -‘regional based training’, 22.5% -‘all of the above’, 4.9%—‘other’.

Conclusion

Our survey suggests non consultant hospital doctors in Ireland strongly desire an expansion of current flexible training options. This is essential to ensure Ireland is an attractive place for doctors to work, to support their health and wellbeing, and to ensure an adequate workforce to care for an ageing population.

194 TIA IMAGING: ARE WE FOLLOWING NICE 2020 GUIDELINES?

Background

CT brain imaging is customary in clinical practice after Transient Ischemic Attack (TIA). However, NICE (2020) guidelines recommend MRI brain with diffusion weighted and blood-sensitive sequences; to be completed on the same day as the assessment. The purpose is to detect the ischemic territory, haemorrhage, or other pathology. The aim of this audit was to assess the diagnostic radiology investigations performed on patients, over the age of sixty-five years, presenting with TIA to a university teaching hospital.

Methods

We conducted a retrospective audit of all patients coded as TIA on the Hospital Inpatient-Enquiry (HIPE) system between July 2019 to July 2020. Data on brain imaging was accessed using the National Integrated Medical Imaging System (NIMIS) system. Hospital attendance records were accessed via the Emergency Department patient database. Data was analysed using Microsoft Excel.

Results

Eighty patients had brain imaging performed (n = 38 CT brain only; n = 1 MRI only; n = 41 CT and MRI). Of these patients, only three had an MRI brain completed within twenty-four hours where thirty-nine patients had an MRI scans outside of twenty-four hours. Forty-one patients had both a CT and MRI brain imaging performed. The median time to MRI brain was three days and one and a half hours and the median time to CT brain was two hours and forty-nine minutes.

Conclusion

This audit confirms duplication of TIA brain imaging and CT as the primary imaging tool for TIA which is not in keeping with best practice (NICE, 2020). This has implications for resources, radiation exposure and patient’s length of stay. Development of dedicated ambulatory care pathways for TIA must incorporate rapid MRI access as the primary imaging modality.

247 BENCHMARKING STROKE SERVICES TO INFORM A QUALITY IMPROVEMENT INIAITIVE

Background

Stroke is a leading cause of death and disability in Ireland. Continuous audit and quality improvement is essential in the delivery of stroke care where the evidence basis is constantly changing. This helps to ensure the delivery of high quality stroke care and compliance with evidenced based guidelines. We aimed to assess stroke care at an Irish university teaching hospital.

Methods

Patients with a HIPE discharge diagnosis of Cerebral Infarction or Cerebral Haemorrhage (1st January-31st December 2019) were identified through both the HIPE database and the institutional Stroke Portal. Data was benchmarked against national (Irish National Audit of Stroke 2019) and international (6th SSNAP Annual Report; American Heart Association, 2013) practice and used to inform a quality improvement strategy.

Results

419 patients were included (56.6% male, median 57 years). 75.9% were aged 65 years or older. We compared favourably with Irish National Audit of Stoke national indicators on the following: thrombolysis rates-10%; median door to needle time-60 mins; stroke unit admissions- 78.5%; median duration of symptoms- 3 hours 6 minutes; swallow assessment- 81.1%; in-patient mortality- 10.5%; rates of institutionalisation- 3.8%. Areas identified for improvement were: thrombectomy rates- 1.9%; median length of stay- 12 days; door to imaging time- median 104 minutes; mood screening- 11.5%.

Conclusion

International and national data is a useful benchmark against which local hospitals can assess the quality of their service. By completing this quality improvement initiative we identified areas to target resources in our centre, including mood screening, swallow screening, thrombectomy rates, length of stay and time to neuroimaging. An ongoing quality improvement process using ‘PDSA’ methodology is being carried out with an annual audit to monitor progress.

235 THROMBOLYSIS DOSING AND WEIGHT ESTIMATION IN ACUTE STROKE: A SINGLE CENTRE AUDIT

Background

Stroke is a leading cause of death and disability. Thrombolysis with intravenous (IV) alteplase is the mainstay management of ischaemic stroke. It has a narrow therapeutic window with a high potential for adverse outcomes such as intracranial haemorrhage. The efficacy of alteplase is time and dose dependent with weight-based dosing. National clinical guidelines recommend a dose of 0.9 mg/kg, up to a maximum of 90 mg. (Irish Heart Foundation Council for Stroke 2015). In most hospitals in Ireland however, patients are not weighed prior to thrombolysis. Time pressure and lack of available suitable equipment are factors.

Methods

This retrospective clinical audit evaluated the dosing of alteplase, estimated and actual weight for a convenience sample of stroke thrombolysis patients treated between 2016–2020 at an Irish University Teaching Hospital.

Results

107 patients were audited (62 males, 45 females). Actual and estimated weights were available in 92/107. Weight was not documented (n = 15) due to severe stroke/palliative management (n = 6) or omission (n = 9). 21% (19/92) received the correct dose of 0.9 mg/kg. A further 54% (50/92) received a dose within the range of 0.81–0.99 mg/kg (±10%). 25% received a dose outside this range (&gt; ± 10%). 11% (10/92) were under-thrombolysed and 14% (13/92) over-thrombolysed. 17/92 patients had an intracranial haemorrhage. 35% (n = 6/17) of patients who had an intracranial haemorrhage received a higher dose of thrombolysis (&gt;10%).

Conclusion

A quarter of patients received inappropriate dosing of alteplase that was outside the range of ±10% of 0.9 mg/kg. While stroke thrombolysis must be completed urgently, an accurate weight should be determined to avoid errors in dosing. A process evaluation of stroke thrombolysis would provide information on how best to incorporate an objective means of weight measurement without delaying treatment.