CWTCH in the community: improving education to reduce adverse outcomes for patients who fall in nursing homes

Falls in nursing homes (NH) are common and cause significant morbidity and mortality. We proposed that by improving staff education, the volume of emergency calls, hospital conveyance and adverse patient outcomes could be reduced. An analysis of the volume of emergency calls coded as Falls from January 2020 to February 2022, with 4907 calls in total, 866 were falls (17.65%), further 1032 potential falls (21.07%). A survey was sent to NH to evaluate how staff treated residents who fell and showed that 47% of NH do not have any guidelines for falls and emergency services, are contacted 88.24% of the time. Education was delivered focusing on the negative consequences of falls. The package used the acronym "CWTCH" translated from the Welsh language as a hug. Education was offered to all NH (177 staff) and Feedback showed 100% felt more confident and found the session helpful with 90.96% less likely to contact emergency services. Falls remain a significant burden on emergency services, with clear opportunity to improve patient outcomes and experience. A referral pathway was developed diverting calls, showing a significant change in conveyance to hospital (p < 0.05).

1193 CWTCH IN THE COMMUNITY - IMPROVING EDUCATION TO REDUCE ADVERSE OUTCOMES FOR PATIENTS WHO FALL IN NURSING HOMES (NH)

Introduction

Falls have significant morbidity and mortality in Nursing Home (NH) residents. By improving education to NH staff we aim to reduce 999 calls and associated adverse outcomes. NH residents are more likely to fall than people living in the community and are more at risk of further falls as interventions and risk factor modification is more difficult.

Methods

Phase 1 - Ambulance calls, where a vehicle attended the scene, between 01/01/2020-28/02/2022 from NH in Swansea Bay University Health Board (SBUHB) concerning Falls/?Falls (Haemorrhage/lacerations, Unconscious/fainting, traumatic injuries, sick person, convulsions/fitting) were analysed and survey was sent out to all NH.

Phase 2 - Education was provided about CWTCH (hug in Welsh) and staff were surveyed post intervention. Can you move them, Will it harm them? - new neck/back pain, anticoagulation, Treat them – analgesia, wound-care, Cup of Tea – can eat and drink, Help – when contact 999.

Results

Phase 1 - Between 01/01/2020-28/02/2022, of 4907 calls, 866 were falls (17.65%) and 1032 ?Falls (21.07%), 60.49% conveyed to hospital. 47% of NH do not have falls guidelines and 100% patients are Nil by Mouth and 88.24% are not moved. Emergency services were contacted 88.24%. Phase 2 - Education was delivered to all NH in Swansea (122 staff). Feedback showed 100% feel more confident in giving food and drink, moving patients, with 90.98% less likely to contact 999 and 75.40% not having previous training with 96.72 % more confident in giving analgesia.

Conclusions

Falls remain a significant burden and a rapid service would improve care with conveyance reduction to 53.1% post education (60.55% pre-education). Future directions include offering this education to NH in Neath/Port Talbot. From March 2022, we offer same-day assessment for NH residents (and others) from primary care and ambulances and are developing a PRN analgesia pathway e.g. PENTHROX.

1103 AN EVALUATION OF A GERIATRICIAN-LED ACUTE MEDICAL ADMISSION UNIT AT MORRISTON HOSPITAL, SWANSEA

Introduction

The medical intake at Morriston Hospital is accepted on two units; Rapid Assessment Unit (RAU) and Acute Medical Assessment Unit. Both were acute physician-led until July 2021

Method

(Phase 1). From July 2021, RAU became geriatrician-led (Phase 2). This evaluation concerns the performance of RAU.

Phase 1 (Acute Physician-Led Unit) Between 01/08/2020-30/06/2021, there were 3102 admissions with a median length of stay (LOS) of 2 days on RAU. 37.2% of patients were discharged directly from the unit. (SBUHB data). A detailed analysis of 496 patients consecutively assessed between November 2020–January 2021 showed a median LOS on RAU of 1, 28.8% were discharged directly from RAU. Overall health board (HB) median LOS for the cohort was 7. In over 70 years, median LOS on RAU was 1, overall HB LOS 9.

Phase 2 (Geriatrician-Led Unit) 1237 patients were assessed July-December 2021, with a median LOS of 2 days. 42.8% of patients were discharged from RAU. (SBUHB data). A detailed analysis of 566 patients consecutively assessed between September-November 2021 showed a median LOS on RAU of 2, 41.7% discharged directly from RAU. Overall HB median LOS for the entire cohort was 5. For the &gt; 70 years, median LOS on RAU was 2, overall HB LOS was 7. Patient flow through assessment areas is dependent on the function of downstream medical wards. Mean LOS within medicine at Morriston increased 1.5 days between Phase 1 and Phase 2.

Results

Acute geriatricians have delivered the 72hr LOS standard that SBUHB has set for assessment areas. The unit has achieved a reduction in overall LOS for the cohort of patients evaluated (p&lt;.01), especially for the &gt; 70 years (p=.007).

Conclusion

This data supported a change in practice; RAU has taken a frailty specific intake since January 2022.

1061 AN EMERGENCY FRAILTY UNIT AS AN INTERVENTION TO PREVENT INPATIENT FALLS IN THE EMERGENCY DEPARTMENT

Introduction

There is evidence that dedicated units that provide comprehensive geriatric assessment can reduce inpatient falls and other iatrogenic harm1. The Emergency Department (ED) in Morriston Hospital has 90,000 attendances a year. 4,000 patients &gt;65 years presented with falls. Between January 2018–November 2021, ED reported 207 incidents of falls via the Health Board Datix System.

Intervention

Phase 1 In April 2018, the Older Person’s Assessment Service (OPAS) (Geriatrician led Multidisciplinary team) began a liaison service to ED, taking referrals from the medical and ED teams for patients presented with frailty syndromes. Phase 2 In June 2020, OPAS was allocated a dedicated Emergency Frailty Unit within the Emergency Department footprint, allowing patients to be assessed rapidly by a specialist team and nursed in a specialist environment.

Results

Between June 2020–November 2021, the service saw 1,317 new patients. The average age of an OPAS patient was 83 years and had a Rockwood Clinical Frailty Scale Score of &gt;5. 73% of patients presented with falls as a primary presenting complaint. Between June 2020–November 2021, there was one reported fall within the unit. The mean incident reported of inpatient falls in ED in phase 2 (M = 5.50, SD = 2.66) is statistically significantly higher than phase 1 (M = 3.96, SD = 1.87), t(42) = −2.26, p = 0.03. The service did not show any impact on the incidence of inpatient falls in ED.

Conclusion

The unit was an effective intervention to prevent falls for the patients it assessed within the unit but had no impact on inpatient falls within the main ED. The impact of this service is difficult to determine given the low reported falls in ED. 1. Fox MT, Persaud M, Maimets I et al. J Am Geriatr Soc, 2012, 60:2237–2,245.

1017 EVALUATION OF FRAILTY DOCUMENTATION PRE AND DURING THE COVID-19 PANDEMIC IN A LARGE REGIONAL CENTRE

Background

Identifying frailty can lead to improvements in patient outcomes through interventions such as CGA and prompt discussions around resuscitation and ACP. [Welsh; International Journal of Clinical Practice; 2014; 290– 293] Frailty is associated with a higher risk of postoperative mortality and morbidity, and mortality due to COVID-19.[Parmar; Annals of Surgery; 2021; 709–718, Dumitrascu; Journal of the American Geriatrics Society; 2021; 2, 419– 2, 429] Our audit considers whether the pandemic had any effect on documentation of frailty, and identifies interventions to improve this process.

Method

We retrospectively reviewed notes to look for elements of social history which identify frailty including mobility, ADLs, and CFS. We conducted a series of spot audits in February 2020 (pre-pandemic), April 2021 (Wave 2), and November 2021 (Wave 3) across surgical and medical wards.

Interventions and Results

February 2020 This cohort consisted of 62 patients and showed poor documentation across both medicine and surgery with an average of only 21% relevant social history recorded and 0% CFS scoring. Interventions that followed included an educational series by geriatricians and introduction of triaging tools based on CFS in response to the pandemic e.g. Swansea Hip interrogation Fracture Tool (SHiFT). [Cronin; British Orthopaedic Association; 2020] April 2021 The relevant documentation improved to an average of 31% in this cohort of 37 patients. Interventions that followed included further educational sessions on frailty, a surgical liaison service, and the appointment of an orthogeriatrician. November 2021 This cohort consisted of 149 patients, average relevant social history continued to improve to 49%. Subgroup analysis showed 76% of orthopaedics patients had a CFS score, including 100% of NOF patients.

Conclusion

Frailty is important as it is linked to an increased risk of mortality and morbidity. In the pre-pandemic cohort, the results were poor. Improvements were seen after interventions such as educational sessions, pandemic triaging tools, and the surgical liaison service. However, there are still inconsistencies between teams. Future interventions include a CFS app, expansion of the surgical liaison service, and improved proformas.

1028 OLDER PERSON’S ASSESSMENT SERVICE (OPAS): DELIVERING COMPREHENSIVE GERIATRIC ASSESSMENT (CGA) IN THE EMERGENCY DEPARTMENT (ED)

Introduction

Innovative models of service delivery are required to provide Comprehensive Geriatric Assessment for older patients presenting to the Emergency Department with frailty syndromes.

Method

In 2018, the Older Person’s Assessment Service began a liaison service to the ED, taking referrals from the medical and ED teams for patients who presented with frailty syndromes (falls, cognitive impairment, care dependence, polypharmacy). The service saw 437 patients April–August 2018. 76% of the patients assessed were discharged by utilising available community services, rapid access outpatient follow up and inpatient reablement off the acute site. The service was estimated to avoid 50–80 admissions per month to medicine (saving 17–23 beds a year) and was commissioned as a permanent service. Phase 2 In 2020, a dedicated unit within ED was allocated to OPAS, enabling the acceptance of patients directly from triage and from the Ambulance Service by direct referral. This provided rapid access to specialist assessment, continued access to Elderly Care services, avoided exposure to coronavirus related admissions and the risks of nosocomial infection associated with admission. The service operates from 8 am-4 pm on weekdays.

Results

Between June 2020 and October 2021, the service saw 1,173 new patients. 988 patients (84.5%) were discharged off the acute site on the day of assessment. 68 (5.79%) patients were admitted to other facilities run by the Health Board (e.g Inpatient Reablement). The average age of an OPAS patient was 83 yrs and had a CFS > 5. Readmission rate at 14 days was 4% (47).Of the 253 patients who were admitted to an inpatient setting, 13.5% (35) contracted nosocomial covid-19.

Conclusion

The service has been supported and funded to expand into extended weekday hours as a result of this success and there are plans for future 7 day working.