240 STANDARDISING POST-FALL MEDICAL REVIEWS FOR HOSPITAL INPATIENTS

Background

Falls are the most common adverse incident of inpatients in Irish hospitals. 6% of inpatient falls cause serious injury. Older inpatients have the highest risk of falling and the highest risk of injury. The post-fall medical review is critical to assess why a patient fell, did the fall cause injury and for the introduction of measures to prevent future falls. We assessed the quality of the post fall reviews in a large hospital. We then introduced a standardised post-fall medical review pro forma and reassessed the quality of the reviews.

Methods

We reviewed 18 charts of patients that fell in hospital and assessed the documentation of the post fall review in terms of the inclusion of key elements such as patient identifiers, history, examination, injury management and future falls prevention. We then introduced a post-fall standardised pro-forma on five wards in the hospital and following this assessed 19 charts of patients who had fallen looking at the same key elements of the post fall review. We compared the quality of the post-fall review before and after the introduction of the pro forma.

Results

The post-falls medical review pro forma improved the quality of the post fall medical review. Hip Trauma: 11.1% of doctors asked about hip strike prior to proforma versus 100% who asked with the proforma. Joint examination: 50% assessed this prior to the proforma versus 100% with the pro-forma. Other aspects of the review that improved included head-strike assessment (89% versus 100%), loss of consciousness history (61% versus 95%), medication reviewed (22% versus 68%) and vital signs assessed (67% versus 95%).

Conclusion

The introduction of a standardised post fall review pro forma improves the quality of this important medical review. It is a useful aid for doctors and provides a framework to follow when reviewing the patient.

269 PHARMACIST INTERVENTIONS WITHIN A MULTIDISCIPLINARY CARE TEAM FOR FRAIL OLDER ADULTS PRESENTING TO A LEVEL 4 EMERGENCY DEPARTMENT

Background

Inappropriate polypharmacy and ‘Potentially Inappropriate Prescriptions’ (PIP) are associated with increased morbidity and hospitalisation, in particular among frail older persons. A structured medication review, in conjunction with a Comprehensive Geriatric Assessment (CGA), can address PIP. The aim of the study was to review Frail Intervention Team (FIT) pharmacist interventions for frail, older adults presenting to the Emergency Department (ED) and experiencing medication compliance difficulties, polypharmacy and PIP.

Methods

Patients identified for medication review included those experiencing polypharmacy or medication compliance issues, presenting with a fall, delirium and/or frailty syndromes or complex comorbidities. The medication review process involved completion of medicines reconciliation and medication appropriateness review in accordance with the 7-Steps Medication Review Model (Scottish Government Polypharmacy Model of Care Group, 2018). Pharmacist optimisation recommendations were reviewed by a Consultant Geriatrician or Registrar and discussed with the patient prior to implementation.

Results

The FIT Pharmacist completed medication reviews for 765 patients between May 2021 and April 2022. The mean age (+/-SD) was 83.1 (+/-7.0) years with a median Clinical Frailty Score (CFS) of 5 (mildly/moderately frail). Medication Optimisation recommendations were actioned in 63% (n=483) of patients reviewed. The most commonly encountered PIP’s included: excessive anti-hypertensive/diuretic therapy, long-term acid-suppression therapy, anticholinergics and long-term prophylactic antimicrobials. Prescribing opportunities identified included: bone protection, laxatives and pain management.

Conclusion

FIT pharmacist review, in conjunction with the CGA, led to medication optimisation interventions in the frail older adult cohort presenting to the ED. Future studies should examine the impact of medication review on patient outcomes post-discharge.

61 AUDIT: MEDICATION REVIEW POST INPATIENT FALLS

Background

Falls are the most commonly reported incident in the Health Service Executive (HSE). Inappropriate medications and polypharmacy in the elderly can contribute to increased falls risk.

Our aim was to assess whether a medication review was being completed at the time of the post-fall clinician review.

Methods

We completed a retrospective chart review using an audit tool of consecutive inpatient falls, resulting in serious injury, from March–December 2019.

Standards measured against were: HSE Guideline—Service User Falls: A Practical Guide for Review, Medicines and Falls in Hospital: British Society Guidelines, STOPP & START criteria and NICE Guidelines: Falls in Older People 2013.

Results

We identified 33 charts for review (n = 33)—54.55% (18) female and 45.45% (15) male. Average age was 81 ± 11.2 years. The immediate post-fall review was mainly completed by interns (48.49% (16)) and SHO’s (39.39% (13)). A medication review was carried out 9.09% (3) of the time.

A total of n = 28 (84.85%) had poly pharmacy. When analysed for medications known to increase risk of falling, 51.52% (n = 17) were on anti-hypertensives, 45.45% (n = 15) on laxatives, 24.24% (n = 8) on sedative medications, 18.18% (n = 6) on hypnotics/anxiolytics, 15.15% (n = 5) on opioids and 15.15% (n = 5) on diuretics at the time of fall. The majority of these medications (77.42% (n = 24)) were commenced prior to admission. None of these medications were discontinued or the dose changed on review post fall.

Conclusion

Our audit demonstrates that in a cohort of patients who had an inpatient fall medication discontinuation and dose reductions were not performed. Yet, a high burden of polypharmacy and high-risk falls medication were found. This may result in missing a pertinent opportunity to prevent future falls. We advise a structured medication review is carried out for each patient who suffers an in-patient fall to efficiently modify such an easily identifiable risk factor.

484 CHANGING PRACTICES OF DECISION MAKING REGARDING DO-NOT-ATTEMPT-CARDIOPULMONARY-RESUSCITATION ORDERS AMID THE COVID-19 PANDEMIC

Introduction

The COVID-19 pandemic has brought the decision-making process regarding cardiopulmonary resuscitation into focus. This study aims to analyse Do-Not-Attempt CPR (DNACPR) documentation in older hospitalised patients before and during the COVID-19 pandemic.

Methods

This was a retrospective repeated cross-sectional study. Data including co-morbidities and resuscitation status was collected on 300 patients with COVID-19 hospitalised from March 1st to May 31 s t 2020. DNACPR documentation rates in patients aged ≥65 years with a diagnosis of COVID-19 were compared to those without COVID-19 admitted during the same period. Pre-COVID-19 pandemic DNACPR documentation rates were also examined. Factors associated with DNACPR order instatement during the first wave of the COVID-19 pandemic were identified.

Results

Of 300 COVID-19-positive patients, 28% had a DNACPR order documented during their admission. 50% of DNAR orders were recorded within 24 hours of a positive swab result for SARS-CoV-2. Of 131 patients aged 65 years or over within the cohort admitted with COVID-19, 60.3% had a DNACPR order compared to 25.4% of 130 patients ≥65 without COVID-19 (p < 0.0001). During a comparable time period pre-pandemic, 15.4% of 130 older patients had a DNACPR order in place (p < 0.0001). Independent associations with DNACPR order documentation included increasing age (Odds Ratio [O.R.] 1.12; 95% CI 1.05-1.21); nursing home resident status (O.R. 3.57; 95% CI 1.02-12.50); frailty (O.R. 3.34; 95% CI 1.16-9.61) and chronic renal impairment (O.R. 5.49; 1.34-22.47). The case-fatality-rate of older patients with COVID-19 was 29.8% versus 5.4% without COVID-19. Of older COVID-19-positive patients, 39.2% were referred to palliative care services and 70.2% survived.

Conclusion

The COVID-19 pandemic has prompted more widespread and earlier decision-making regarding resuscitation status. Although case-fatality-rates were higher for older hospitalised patients with COVID-19, many older patients survived the illness. Advance care planning should be prioritised in all patients and should remain clinical practice despite the pandemic.

Stroke recurrence within the time window recommended for carotid endarterectomy

OBJECTIVE

In the North Dublin Population Stroke Study, we investigated the risk of recurrent stroke within the 14-day time window recommended for endarterectomy.

METHODS

In a population-based prospective cohort study, all ischemic stroke patients were identified over 1 year and categorized into those with (CS-positive) and without (CS-negative) ipsilateral carotid stenosis (CS) (≥50% lumen narrowing). Nonprocedural stroke recurrence was determined at 72 hours and 7 and 14 days.

RESULTS

Of 365 ischemic stroke patients with carotid imaging, 51 were excluded due to posterior circulation or nonlateralizing stroke, ipsilateral carotid occlusion, or intracranial stenosis, leaving 314 included for analysis (36 CS-positive and 278 CS-negative). Recurrent stroke occurred in 5.6% (2/36) CS-positive and 0.4% (1/278) CS-negative patients by 72 hours of symptom onset (p =0.003), 5.6% (2/36) CS-positive and 0.7% (2/278) CS-negative patients (p =0.01) by 7 days, and in 8.3% (3/36) CS-positive and 1.8% (5/278) CS-negative patients by 14 days (p =0.02). On multivariable Cox regression analysis, CS was the only independent predictor of recurrence at 72 hours (adjusted hazard ratio [HR] 36.1, 95% confidence interval [CI] 1.6-837.5, p =0.03), and 7 days (HR 9.1, 1.1-79.2, p =0.05), with a trend at 14 days (HR 4.6, 0.9-22.8, p =0.06).

CONCLUSIONS

Although only a minority of patients with symptomatic CS had a recurrent stroke within 14 days, early recurrent stroke risk was high, particularly within the first 72 hours. Earlier carotid revascularization or improved acute medical treatment may reduce recurrence in this high-risk group.

The increased mortality associated with a weekend emergency admission is due to increased illness severity and altered case-mix

BACKGROUND

A weekend emergency medical admission has been associated with a higher mortality. We have examined all weekend admissions to St James' Hospital, Dublin between 2002 and 2009.

METHODS

We divided admissions by weekday or weekend (Saturday or Sunday) presentation. We utilised a multivariate logistic model, to determine whether a weekend admission was independently predictive of 30 day outcome.

RESULTS

There were 49337 episodes recorded in 25883 patients; 30-day inhospital mortality at the weekend (9.9% vs. 9.0%) had an unadjusted Odds Ratio of 1.11 (95% CI 0.99, 1.23: p=0.057). In the full risk unlike the univariate) model, a weekend admission was not independently predictive (OR 1.05; 95% CI: 0.88, 1.24). The case-mix for a weekend admission differed; with more neurological diagnoses (22.8% vs 20.4% : p = 0.001) and less gastrointestinal disease (18.3% vs 21.1% : p = 0.001). A biochemistry only illness severity score predicted a higher mortality for weekend admissions.

CONCLUSION

Patients admitted at the weekend had an approximate 11% increased 30-day in-hospital mortality, compared with a weekday admission. However, admission at the weekend was not independently predictive in a risk model that included Illness Severity (age and biochemical markers) and co-morbidity. Sicker patients, with a worse outcome, are admitted over the weekend; these considerations should inform the allocation of healthcare resources.