Acute Medical Assessment Unit Research Articles

323 A service evaluation of a new initiative; the Mercers Acute Medical Assessment Unit for Older Adults (MASU)

323 A service evaluation of a new initiative; the Mercers Acute Medical Assessment Unit for Older Adults (MASU)

Co-developing, piloting, and evaluating a translational simulation (TS) delivery model for the promotion of psychological trauma-informed care (TIC) to improve service delivery within acute hospital settings: A Research Protocol

Background: Over 70% of the general population have experienced at least one psychologically traumatic event in their lifetime, with 30.5% experiencing four or more events. Recognising the prevalence and potentially injurious effects of psychological trauma among healthcare workers and patients alike is considered important to ensure patient engagement, quality of care, positive health outcomes, as well as improved staff wellness, and more resilient health systems. Aim: The current project aims to improve the experience of both patients and staff in two acute hospital settings in St James’ Hospital (SJH): the Emergency Department (ED) and Acute Medical Assessment Unit (AMAU). This will be achieved through the development of a translational simulation improvement programme for trauma-informed care (TS4TIC). The objective of trauma-informed care (TIC) in the acute hospital setting is to reduce the impact of previous trauma on the care experience. Methods: Underpinned the Institute for Healthcare Improvement (IHI) Model for Improvement we will (i) co-design a TIC improvement programme for use in acute hospital settings using translational simulation (TS) approaches, (ii) implement TS4TIC in two acute hospital settings, and (iii) co-evaluate the effectiveness and acceptability of TS4TIC using co-defined outcome, process, and balancing indicators measured across iterative Plan, Do, Study, Act (PDSA) cycles. Expected Outcome: The project’s completion will result in a co-designed, open access TS4TIC Toolkit, consisting of a suite of TS scenarios and accompanying monitoring and training resources to guide the adaptation of this approach for use in other acute healthcare settings nationally and internationally.

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

Abstract 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 > 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<.01), especially for the > 70 years (p=.007). Conclusion This data supported a change in practice; RAU has taken a frailty specific intake since January 2022.

Does Estimated Glomerular Filtration Rate Predict In-Hospital Mortality in Acutely Unwell Hospitalized Oldest Old?

Globally the population of older adults is the fastest growing age group. Estimated glomerular filtration rate (eGFR) is an estimation of true kidney function with lower eGFR associated with higher mortality. However, few studies explore eGFR's prognostic value in the nonagenarian. We investigated the association between eGFR on admission and mortality among the nonagenarians hospitalised with acute illness. A retrospective analysis of a prospective cohort study included patients aged ≥ 90 admitted into three acute medical assessment units or acute geriatric wards in England and Scotland between November 2008 and January 2009. Association between eGFR and all-cause mortality was evaluated using the Cox proportional hazard models controlling for potential confounders including frailty. 392 patients with mean (SD) 93.0 ± 2.6 years (68.45% women) were included. The median (IQR) eGFR was 26.61 (18.41-40.41) mL/min/1.732. 63 died in in hospital. Low eGFR was not associated with mortality (Hazard ratio (HR) 1.00 (95% CI 0.98-1.02) overall or in sub-group analysis by frailty (HR 0.96 (0.92-1.01)) or by eGFR of ≤30 (HR 1.01 (0.95-1.06). We found no evidence of prognostic value of eGFR in predicting in-hospital mortality in the acutely unwell hospitalised nonagenarians.

25 EVALUATION OF PATIENTS PRESENTING WITH TIA IN THE AMAU AND TIA FAST ASSESSMENT CLINICS - ARE WE MEETING ESO GUIDELINES?

Abstract Background The European Stroke Organisation published guidelines on the management of Transient Ischaemic Attack (TIA) in 2021. Specialist review of suspected TIA is recommended within 24-hours of symptom onset in a TIA clinic. They suggest using CT or MR angiogram for additional confirmation of large artery stenosis of >50%. They advise against the use of prediction tools alone e.g. ABCD2 score when identifying high-risk patients. Dual antiplatelet therapy is recommended short-term in high risk, non cardio-embolic TIA patients. This audit evaluates if these guidelines are being followed in our institution. Methods We evaluated all patients attending the TIA clinic and the Acute Medical Assessment Unit (AMAU) with suspected TIA over a three-week period in 2021 in a single tertiary referral centre. Retrospective data was collected based on chart review. Results Twenty patients underwent review in the TIA clinic and eight in the AMAU with suspected TIA in the chosen time period. One patient (3.5%) was seen within 24 hours from symptom onset, 2 were seen within 24-36 hours (7.1%), 4 patients (14.2%) were seen within 36-72 hours, 21 patients (75%) were seen >72 hours after symptom onset. In all patients who had a doppler US showing >50% carotid stenosis, a CT angiogram was performed. ABCD2 scores were recorded but used in combination with clinical judgment. All patients with high-risk, non-cardioembolic TIA received early, short-term dual antiplatelet therapy. Conclusion The diagnostic methods and treatment strategies in place for patients attending the TIA clinic or AMAU with TIA were in keeping with the recently published ESO guidelines. However, there was a time delay from symptom onset to time of review in many patients. Further studies are indicated to identify the potential mechanisms behind these delays. Interventions to ensure that we are meeting this ‘time-to-review’ target in patients could be implemented, ensuring high quality, evidence-based care.

The appropriateness of abdominal X-ray requests in the acute medical initial admissions unit.

Abdominal X-rays are frequently requested by clinicians in the Aberdeen Royal Infirmary acute medical initial assessment unit. The proportion of indicated abdominal X-rays requested within 24 hours of admission was retrospectively examined. This process was repeated after displaying an educational poster with the Royal College of Radiologists guidelines (cycle 2) and a graded assertive communication poster (cycles 3 and 4); a tool to enable junior doctors to challenge inappropriate requests for abdominal X-rays from seniors. Only 47.2% of abdominal X-ray requests were deemed appropriate in cycle 1. A 1.54% reduction in abdominal X-ray requests and an 11.5% increase in indicated abdominal X-rays were noted after cycle 2. Cycle 3 led to a statistically significant improvement with 2.6% fewer patients undergoing an abdominal X-ray and a 24.6% increase in indicated abdominal X-rays. This improvement was sustained in cycle 4. Promoting graded assertive communication is an effective means of helping junior doctors to challenge seniors requesting non-indicated abdominal X-rays.

798 SPOT DELIRIUM - IMPROVING DELIRIUM AWARENESS AND ASSESSMENT USING ELECTRONIC 4AT

Abstract Introduction Delirium is a common medical emergency which is associated with adverse outcomes but often unrecognised in up to two thirds of patients in the acute care setting. The 4AT is a sensitive and rapid assessment tool that can be applied to assess for delirium in clinical practice. Method An initial audit into the use of delirium diagnostic assessment scores on an Acute Medical Assessment Unit (AAU) was carried out. Medical notes were reviewed of patients over 75 years (n = 42) admitted over a 6 week period. A re-audit was undertaken following an educational induction session for junior doctors about delirium and 4AT (n = 42). Results Initially 14% of patients with documented acute confusion (n = 2) had a 4AT assessment completed. 2 patients were recognised to be at risk of delirium but did not have a 4AT. A diagnosis of dementia was documented for 28% (n = 12) of patients however only one had a 4AT. An educational session about delirium and how to complete the electronic 4AT assessment was organised for junior doctors on AAU. Before teaching, survey results showed no participants were familiar with the 4AT screening tool. Following the session all participants indicated knowing where to locate the electronic 4AT and reported improved confidence in recognising delirium. On re-audit 14 patients had documented confusion but 4AT assessment completion increased to 79%. For those identified as being at risk of delirium or having previous delirium 90% had a 4AT completed. All patients with a dementia had an AMTS and 89% also had a 4AT. Conclusion There was an improvement in documentation of both 4AT and AMTS forms following engagement in education and use of an electronic assessment tool to diagnose delirium. Future recommendations include interdisciplinary induction sessions to target a wider audience to improve awareness and recognition of delirium in acute care.

Decreasing insulin wastage in acute medical assessment units at Hamad General Hospital

Background: Insulin therapy is commonly used to control hyperglycemia in hospitalized diabetic patients. There are different delivery devices of Aspart and Glargine insulin which are available in 1000 IU vial and 300 IU Flexpen. As per the manufacturer's recommendations, insulin pre-filled pens are designed for single patient use only, whereas the vial form is intended for multidose administration for different patients, therefore, the selection amongst both forms of insulin will certainly impact the consumption cost. According to our observation, there was an unjustified prescribing discrepancy between both forms. Several studies have shown a decrease in insulin wastage associated reduction in acquisition costs when switching from pre-filled pens to vials1-3. Methods: This is a quality improvement project that aims to enhance prescribing insulin vials in acute medical units at Hamad General Hospital. Insulin consumption data were retrospectively reviewed between July 2020-May 2021. Data were obtained 3 months consecutively at baseline and post improvement interventions which consist of 2 steps. Step 1: educating physicians and nurses about the cost effectiveness of insulin delivery devices, and Step 2: Transitioning patients from insulin Flexpen to vials by an authorized pharmacist. The outcomes measures were related to insulin consumption and cost reduction. The process was measured by the amount of Flexpens dispensed. Results: From July-October 2020, 400 patients consumed 81500 IU of insulin Aspart and 58600 IU of insulin Glargine, with a total number of 297 Flexpens used. After implementing improvement intervention, insulin consumption for 551 patients from February – May 2021 reduced to 19200 IU (76.4%) for Aspart and 18900 IU (67.7%) Glargine (Figure 1), comparing with same interval period only 38 Flexpens were dispensed. Economically, the transition to insulin vials reduced the hospital cost by 71% (Table 1). Conclusion: Compared to Flexpen, insulin vial prescribing in hospitalized diabetic patients led to waste and cost consumption reduction of insulin.

A physiotherapy-led transition to home intervention for older adults following emergency department discharge: protocol for a pilot feasibility randomised controlled trial

BackgroundOlder 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. This paper reports a protocol designed to evaluate the feasibility of conducting a three arm randomised controlled trial (RCT) within the ED setting and in the patient’s home. The interventions are comprehensive geriatric assessment (CGA), ED PLUS and usual care.MethodsThe ED PLUS pilot trial is designed as a feasibility RCT conducted in the ED and Acute Medical Assessment Unit of a university teaching hospital in the mid-west region of Ireland. We aim to recruit 30 patients, aged 65 years and over presenting to the ED with undifferentiated medical complaints and discharged within 72 h of index visit.Patients will be randomised by a computer in a ratio of 1:1:1 to deliver usual care, CGA or ED PLUS during a 6-month study period. A randomised algorithm is used to perform randomization. CGA will include a medical assessment, medication review, nursing assessment, falls assessment, assessment of mobility and stairs, transfers, personal care, activities of daily living (ADLs), social supports and baseline cognition. ED PLUS, a physiotherapist led, multidisciplinary intervention, aims to bridge the transition of care between the index visit to the ED and the community by initiating a CGA intervention in the ED and implementing a 6-week follow-up self-management programme in the patient’s own home following discharge from the ED. The outcomes will be parameters of the feasibility of the intervention and trial methods and will be assessed quantitatively and qualitatively.DiscussionRising ED visits and an ageing population with chronic health issues render ED interventions to reduce adverse outcomes in older adults a research priority. This feasibility RCT will generate data and experience to inform the conduct and delivery of a definite RCT.Trial registrationThe trial was registered in Clinical Trials Protocols and Results System as of 21st July 2021, with registration number NCT049836020.

Time for change in practice of in-patient oxygen therapy: a period-limited, multidimensional approach to improve oxygen prescription compliance: quality improvement project at Hamad General Hospital, Qatar

Prescription of oxygen therapy has traditionally poor compliance across the globe and mostly given to patients on verbal orders leading to under or overuse. The British Thoracic Society (BTS) guidelines...

The impact of frailty Screening of Older adults with muLtidisciplinary assessment of those At Risk during emergency hospital attendance on the quality, safety and cost-effectiveness of care (SOLAR): a randomised controlled trial.

BackgroundOlder people account for 25% of all Emergency Department (ED) admissions. This is expected to rise with an ageing demographic. Older people often present to the ED with complex medical needs in the setting of multiple comorbidities. Comprehensive Geriatric Assessment (CGA) has been shown to improve outcomes in an inpatient setting but clear evidence of benefit in the ED setting has not been established. It is not feasible to offer this resource-intensive assessment to all older adults in a timely fashion. Screening tools for frailty have been used to identify those at most risk for adverse outcomes following ED visit. The overall aim of this study is to examine the impact of CGA on the quality, safety and cost-effectiveness of care in an undifferentiated population of frail older people with medical complaints who present to the ED and Acute Medical Assessment Unit.MethodsThis will be a parallel 1:1 allocation randomised control trial. All patients who are ≥ 75 years will be screened for frailty using the Identification of Seniors At Risk (ISAR) tool. Those with a score of ≥ 2 on the ISAR will be randomised. The treatment arm will undergo geriatric medicine team-led CGA in the ED or Acute Medical Assessment Unit whereas the non-treatment arm will undergo usual patient care. A dedicated multidisciplinary team of a specialist geriatric medicine doctor, senior physiotherapist, specialist nurse, pharmacist, senior occupational therapist and senior medical social worker will carry out the assessment, as well as interventions that arise from that assessment. Primary outcomes will be the length of stay in the ED or Acute Medical Assessment Unit. Secondary outcomes will include ED re-attendance, re-hospitalisation, functional decline, quality of life and mortality at 30 days and 180 days. These will be determined by telephone consultation and electronic records by a research nurse blinded to group allocation.Ethics and disseminationEthical approval was obtained from the Health Service Executive (HSE) Mid-Western Regional Hospital Research Ethics Committee (088/2020). Our lay dissemination strategy will be developed in collaboration with our Patient and Public Involvement stakeholder panel of older people at the Ageing Research Centre and we will present our findings in peer-reviewed journals and national and international conferences.Trial registrationClinicalTrials.gov NCT04629690. Registered on November 16, 2020

Is Comprehensive Geriatric Assessment Admission Avoidance Hospital at Home an Alternative to Hospital Admission for Older Persons? : A Randomized Trial.

Delivering hospital-level care with comprehensive geriatric assessment (CGA) in the home is one approach to deal with the increased demand for bed-based hospital care, but clinical effectiveness is uncertain. To assess the clinical effectiveness of admission avoidance hospital at home (HAH) with CGA for older persons. Multisite randomized trial. (ISRCTN registry number: ISRCTN60477865). 9 hospital and community sites in the United Kingdom. 1055 older persons who were medically unwell, were physiologically stable, and were referred for a hospital admission. Admission avoidance HAH with CGA versus hospital admission with CGA when available using 2:1 randomization. The primary outcome of living at home was measured at 6 months. Secondary outcomes were new admission to long-term residential care, death, health status, delirium, and patient satisfaction. Participants had a mean age of 83.3 years (SD, 7.0). At 6-month follow-up, 528 of 672 (78.6%) participants in the CGA HAH group versus 247 of 328 (75.3%) participants in the hospital group were living at home (relative risk [RR], 1.05 [95% CI, 0.95 to 1.15]; P = 0.36); 114 of 673 (16.9%) versus 58 of 328 (17.7%) had died (RR, 0.98 [CI, 0.65 to 1.47]; P = 0.92); and 37 of 646 (5.7%) versus 27 of 311 (8.7%) were in long-term residential care (RR, 0.58 [CI, 0.45 to 0.76]; P < 0.001). The findings are most applicable to older persons referred from a hospital short-stay acute medical assessment unit; episodes of delirium may have been undetected. Admission avoidance HAH with CGA led to similar outcomes as hospital admission in the proportion of older persons living at home as well as a decrease in admissions to long-term residential care at 6 months. This type of service can provide an alternative to hospitalization for selected older persons. The National Institute for Health Research Health Services and Delivery Research Programme (12/209/66).

An aide mémoire: working on acute medical assessment units

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Patients with Community Acquired Pneumonia Exhibit Depleted Vitamin C Status and Elevated Oxidative Stress.

Pneumonia is a severe lower respiratory tract infection that is a common complication and a major cause of mortality of the vitamin C-deficiency disease scurvy. This suggests an important link between vitamin C status and lower respiratory tract infections. Due to the paucity of information on the vitamin C status of patients with pneumonia, we assessed the vitamin C status of 50 patients with community-acquired pneumonia and compared these with 50 healthy community controls. The pneumonia cohort comprised 44 patients recruited through the Acute Medical Assessment Unit (AMAU) and 6 patients recruited through the Intensive Care Unit (ICU); mean age 68 ± 17 years, 54% male. Clinical, microbiological and hematological parameters were recorded. Blood samples were tested for vitamin C status using HPLC with electrochemical detection and protein carbonyl concentrations, an established marker of oxidative stress, using ELISA. Patients with pneumonia had depleted vitamin C status compared with healthy controls (23 ± 14 µmol/L vs. 56 ± 24 µmol/L, p < 0.001). The more severe patients in the ICU had significantly lower vitamin C status than those recruited through AMAU (11 ± 3 µmol/L vs. 24 ± 14 µmol/L, p = 0.02). The pneumonia cohort comprised 62% with hypovitaminosis C and 22% with deficiency, compared with only 8% hypovitaminosis C and no cases of deficiency in the healthy controls. The pneumonia cohort also exhibited significantly elevated protein carbonyl concentrations compared with the healthy controls (p < 0.001), indicating enhanced oxidative stress in the patients. We were able to collect subsequent samples from 28% of the cohort (mean 2.7 ± 1.7 days; range 1–7 days). These showed no significant differences in vitamin C status or protein carbonyl concentrations compared with baseline values (p = 0.6). Overall, the depleted vitamin C status and elevated oxidative stress observed in the patients with pneumonia indicates an enhanced requirement for the vitamin during their illness. Therefore, these patients would likely benefit from additional vitamin C supplementation to restore their blood and tissue levels to optimal. This may decrease excessive oxidative stress and aid in their recovery.

Abstract TP359: Rapid Access Stroke Unit - A Virtual Clinic to Assess Minor Stroke Admissions, Expedite Investigations and Implement Timely Treatments

Background: The current Stroke service is seeing more than 200 patients per month admitted to our acute tertiary hospital. Acute major stroke patients are admitted to the stroke ward but many of the minor strokes or mimics are admitted to an acute medical assessment unit (AMAU) waiting on average 3 days for completion of investigations. TIA clinics are an established element of a stroke service in other countries. We established a similar service, the Rapid Access Stroke Unit (RASU), opened daily in July 2018 aiming to reduce admission rates by expediting investigations and treatments for patients presenting with minor or resolved symptoms. The referral criteria for RASU is a CT scan with no evidence of hyperacute stroke and the Patient is independent in ADL’s. If the patient is in hospital the clinical nurse specialist will triage patients for suitability for transfer to RASU. Out of hours suitable patients can be discharged from ED with instructions to attend RASU the following morning. The clinical nurse specialist, supported by the Stroke Consultant, will coordinate the investigations, track results, organise reviews and ensure the patients are fully educated of diagnosis, treatment and risk factor management. Results: The first year’s figures show a decrease in the inpatient admissions with 496 patients attending RASU, saving 1749 bed days. There is also an increase in the number of patients discharged directly home from the Emergency Department (ED), with the option of attending RASU if required. The diagnosis of patients admitted to RASU are 102 ischemic, 145 TIA, 247 Mimics and 1 ICH. Conclusion: One-year results have shown a significant benefit in patient care, early discharge and improved use of the hospital resources. One unexpected result was the increase in discharges from ED and this may be attributed to the ED physicians discharging patients confident that there is a rapid access service available. Another consequence of the service is that patients will ‘walk in’ to RASU if they have any further concerns or require clarification of treatments.

A multistage mixed methods study protocol to evaluate the implementation and impact of a reconfiguration of acute medicine in Ireland\u2019s hospitals

BackgroundTo address deficits in the delivery of acute services in Ireland, the National Acute Medicine Programme (NAMP) was established in 2010 to optimise the management of acutely ill medical patients in the hospital setting, and to ensure their supported discharge to primary and community-based care. NAMP aims to reduce inappropriate hospital admissions, reduce length of hospital stay and ensure patients receive timely treatment in the most appropriate setting. It does so primarily via the development of Acute Medical Assessment Units (AMAUs) for the rapid assessment and management of medical patients presenting to hospitals, as well as streamlining the care of those admitted for further care. This study will examine the impact of this programme on patient care and identify the factors influencing its implementation and operation.MethodsWe will use a multistage mixed methods evaluation with an explanatory sequential design. Firstly, we will develop a logic model to describe the programme’s outcomes, its components and the mechanisms of change by which it expects to achieve these outcomes. Then we will assess implementation by measuring utilisation of the Units and comparing the organisational functions implemented to that recommended by the NAMP model of care. Using comparative case study research, we will identify the factors which have influenced the programme’s implementation and its operation using the Consolidated Framework for Implementation Research to guide data collection and analysis. This will be followed by an estimation of the impact of the programme on reducing overnight emergency admissions for potentially avoidable medical conditions, and reducing length of hospital stay of acute medical patients. Lastly, data from each stage will be integrated to examine how the programme’s outcomes can be explained by the level of implementation.DiscussionThis formative evaluation will enable us to examine whether the NAMP is improving patient care and importantly draw conclusions on how it is doing so. It will identify the factors that contribute to how well the programme is being implemented in the real-world. Lessons learnt will be instrumental in sustaining this programme as well as planning, implementing, and assessing other transformative programmes, especially in the acute care setting.

An Unusual Case of Palpitations: Pectus Excavatum

We recently encountered a 67-year-old lady who was sent by her GP to our Acute Medical Assessment Unit with complains of palpitations. These were significantly affecting her day to day activities. She described the palpitations as a 'thumping' sensation in the chest with 'skipping beats' without any associated shortness of breath, pre syncope or collapse. The symptoms were prominent at lying flat very short lived and the number of events increased over time.

How good are doctors at introducing themselves? #hellomynameis

BackgroundThis explorative study was triggered by the ‘#hellomynameis’ campaign initiated by Dr Kate Granger in the UK. Our objectives were twofold: first, to measure rates of introduction in an Irish...

Handover Structure and Quality in the Acute Medical Assessment Unit: A Prospective Observational Study.

Inadequate patient handovers are associated with the occurrence of medical errors. The objective of the present study was to explore the structure and quality of handovers in the acute medical assessment unit. A prospective observational study was conducted in an academic hospital in the Netherlands. Handover structure was observed by ordering handover information according to the elements of the Situation, Background, Assessment, Recommendation, and Read back (SBAR-R) handover tool. Handover quality was measured by means of a questionnaire, i.e., the rating tool for handover quality, and by assessing situation awareness of the degree to which professionals after a handover agreed on the complexity of the patient's care needs. A total of 71 handovers were observed. In most handovers, different elements of the SBAR-R were used frequently (median, 7.5 elements; range, 2.0-15.0). On the quality of handovers, 109 respondents (44.1%) completed the questionnaire. On a 0-to-100 scale, median scores on information transfer were 67.9 (interquartile range [IQR],17.9), 75.0 (IQR, 25.0) on shared understanding, and 75.0 (IQR, 16.7) on working atmosphere. Agreement in situation awareness was 70.0%. Handovers in the acute medical assessment unit were poorly structured; however, the perceived quality of handovers was substantial. Implementing the SBAR-R may be an effective strategy to improve handover practice and situation awareness, although further study to its applicability in acute medical assessment units is necessary.

Role of the Dietitian within the Frail Elderly Pilot in Connolly Hospital Blanchardstown from February to June 2016

Introduction : The Specialist Geriatric Services Model of Care aims to improve the quality and efficiency of care for the older person with complex health care needs whom may warrant a comprehensive multidisciplinary assessment. Nutritional status should be a component of the CGA (HSE, 2012). 27% of those admitted to hospital are at risk of malnutrition (BAPEN, 2012). The Frail Elderly Pilot Programme commenced in Connolly Hospital Blanchardstown in January 2016. Aims : - Development of referral criteria to the Dietitian within the Frail Elderly Team - Early identification and nutritional assessment of those at risk of malnutrition - Early identification of those requiring management of chronic disease Methods : - A specialist geriatric team was established within the emergency department (ED) and acute medical assessment unit (AMAU) in CHB - Patients 75 years or more were screened for frailty indicators during core hours including social factors, mobility, swallowing problems and weight loss - A Health and Social Care Professional common screen is performed on selected patients on admission to the ED or AMAU - Development of a referral pathway to Dietitian within the Frail Elderly Team - Same day nutritional assessment of patients following receipt of referral from the Frail Elderly Team from February to June 2016 Results : There was 136 referrals to the Dietitian from the ED and AMAU. There has been an 83% increase in Dietitian referrals of those aged ≥ 75 yrs from February to June 2016 compared to the same months in 2015. 31% of those referred to the Dietitian were at high risk of malnutrition. Patients classified as high risk of malnutrition had a longer length of stay in hospital. Of the recorded anthropometric measurements, 84% were below the 25th centiles for hand grip strength. 26% of Dietitian referrals in ED / AMAU were secondary to management of chronic disease. A standard operating precedure regarding the role of the dietitian within the Frail Elderly Team is also being developed throughout the pilot. Conclusions : - Malnutrition increases a patient’s risk of serious but potentially avoidable complications (IrSPEN, 2015). - The main reason for referral to the Dietitian was secondary to high risk of malnutrition and weight loss which accounted for 45% of all referrals. - Nutrition screening on admission is recommended for the early identification of those at risk of malnutrition whom may warrant nutrition support (HIQA, 2016). - 26% of Dietitian referrals in ED / AMAU were secondary to management of chronic disease e.g. diabetes, heart failure. - The National Clinical Programme for Older Persons recommends that the Dietitian should be part of the multidisciplinary team (HSE, 2012). The Frail Eldely Pilot in Connolly Hospital Blanchardstown plans to continue into 2017. Lessons Learned : Importance of early multidisciplinary assessment of the frail older person on admission to the emergency department and promotion of frail elderly pilot hospital wide