Avoidable Admissions Research Articles

Using stochastic simulation modelling to study occupancy levels of decentralised admission avoidance units in Norway

ABSTRACT Identifying alternatives to acute hospital admission is a priority for many countries. Over 200 decentralised municipal acute units (MAUs) were established in Norway to divert low-acuity patients away from hospitals. MAUs have faced criticism for low mean occupancy and not relieving pressures on hospitals. We developed a discrete time simulation model of admissions and discharges to MAUs to test scenarios for increasing absolute mean occupancy. We also used the model to estimate the number of patients turned away as historical data was unavailable. Our experiments suggest that mergers alone are unlikely to substantially increase MAU absolute mean occupancy as unmet demand is generally low. However, merging MAUs offers scope for up to 20% reduction in bed capacity, without affecting service provision. Our work has relevance for other admissions avoidance units and provides a method for estimating unconstrained demand for beds in the absence of historical data.

Nutrition nurse-led outpatient ‘hot’ clinics are efficient and cost-effective: a retrospective single-centre evaluation

Nutrition nurses work in multidisciplinary and nurse-led outpatient clinics. The daily nutrition nurse-led 'hot' clinic in this study sees patients for enteral or home parenteral nutritional support. Appointments may be for routine procedures or emergency reviews. This study aimed to identify activities and procedures performed in the nutrition nurse-led clinic, identifying admission avoidance activity. Nurse-held records for the period from April 2018 to March 2020 were reviewed retrospectively. Data were collated in an Excel spreadsheet for analysis and results are presented using descriptive statistics. Records covered a total of 590 patients, 294 men and 296 women with a median age of 59 years, and 606 procedures. Key activities were troubleshooting enteral feeding tubes (29%), insertion of fine-bore nasogastric feeding tubes (18%) and management of home parenteral nutrition issues (11%). The presenting problem or issue was resolved in 90% of patients, with no need for hospital admission or additional medical review. The nutrition nurse-led clinic provides an efficient and cost-effective service, preventing hospital admission and emergency department attendance in most cases.

Personalised Assessment and Rapid Intervention in Frail Patients With Lung Cancer: The Impact of an Outpatient Occupational Therapy Service

IntroductionLung cancer and its treatments cause or accelerate frailty, detrimentally affecting function and quality of life. Occupational therapists (OTs) provide global assessments and interventions, but services are often available for inpatients. The impact of holistic assessment and early intervention in the outpatient setting is unknown. Materials and MethodsA tertiary cancer center in North East England piloted a Lung Cancer Outpatient OT Service for patients with thoracic malignancy and a Clinical Frailty Scale Score (CFS) ≥ 5. Service effectiveness was evaluated through calculation of admission avoidance, hospital length-of-stay reduction, completion/impact of advance care planning and patient/family feedback. Demographics, frailty level, required interventions, and onward referrals were recorded. ResultsA total of 153 patients (median age of 71 (range 46-90) received OT assessment and intervention. 48% were in the lowest socioeconomic quintile. Median CFS score was 5 (mildly frail (range: 4-7)) at initial assessment. Total of 918 interventions were delivered (median: 5, IQR: 3-7, Range 0-22). 48% of patients engaged in future planning (national average: 10%-15% P < .0001) and 78.5% achieved preferred place of death (national average 30%). An estimated 37 hospital admissions were avoided. In admitted patients, average inpatient stay when known to the service was 6.5 days less than other frail lung cancer patients in our unit (95% CI 4-9.1 days P < .0001). Higher CFS was associated with poor survival (P < .05). ConclusionOutpatient OT services can avoid and shorten hospital admissions through advance care planning, management of functional disruption, onward referral to other allied health professionals and palliative care. A comprehensive multidisciplinary outpatient service may benefit patients further and should be the focus of future research.

Oxygen saturation thresholds for bronchiolitis at high altitudes: a cost-effectiveness analysis

ABSTRACT Background There is evidence suggesting that exaggerated reliance on pulse oximetry (SpO2) and the use of arbitrary/inadequate thresholds of SpO2 might drive unnecessary hospitalizations for viral bronchiolitis, especially among high-altitude residents. The aim of the present study was to compare the cost-effectiveness of two oxygen SpO2 thresholds for deciding whether infants with viral bronchiolitis living at high altitudes need hospital admission or can be discharged home. Methods A cost-effectiveness study was performed to compare the cost and clinical outcomes of two oxygen SpO2 thresholds, adjusted or not, to an altitude above the sea level of Bogota, Colombia (2640 m), for deciding whether infants with viral bronchiolitis need hospitalization or can be discharged home. The principal outcome was avoidance of hospital admission. Results Compared to the use of an SpO2 threshold of 90%, using an SpO2 threshold of 85% in infants with viral bronchiolitis was associated with lower overall costs (US$130.4 vs. US$194.0 average cost per patient) and a higher probability of hospitalization avoided (0.7500 vs. 0.5900), thus leading to dominance. Conclusions The use of an SpO2 threshold below 90% for deciding on hospitalization in infants with viral bronchiolitis living at high altitudes appears to be logical, secure, and cost-effective.

GP roles in emergency medical services: a systematic mapping review and narrative synthesis.

A significant proportion of emergency medical services (EMS) work is for problems that may be amenable to timely primary care management and could benefit from GP input. Utilising GPs in EMS may reduce avoidable emergency department (ED) conveyance, releasing emergency ambulances for higher-acuity care, and meeting patient needs earlier in the evolution of an emergency call. To collate and summarise evidence on how GPs are utilised in EMS. Systematic mapping review and narrative synthesis. A systematic literature search was conducted using search terms for general practice and emergency care. Primary research articles investigating the utilisation of GPs in non-critical EMS were included. An inductive framework was used to structure the results alongside a narrative synthesis. Twenty-one articles were included. GPs were embedded in EMS for urgent management of high-acuity patients or used as an intervention to avoid unnecessary ED conveyance in selected lower-acuity patients. The importance of interprofessional relationships and training for GPs involved in EMS was highlighted. No studies explored patient-reported outcomes. Outcomes measured were predominantly ED non-conveyance and admission avoidance, with GP services as an intervention reducing the likelihood of these outcomes. Embedding GPs in EMS might service different purposes depending on context. There is some evidence that GP EMS services may reduce the likelihood of ED conveyance and hospital admission in selected cases; it is unclear whether this is owing to case selection or GP involvement. Future research should incorporate patients' views and experiences.

Technology-enabled virtual ward for COVID management of the elderly and immunocompromised in Singapore: a descriptive cohort

BackgroundTo address the hospital bed demand for Delta and Omicron surges in Singapore, the National University Health System (NUHS) developed a COVID Virtual Ward to relieve bed pressures on its three acute hospitals—National University Hospital, Ng Teng Fong General Hospital, Alexandra Hospital. To serve a multilingual population, the COVID Virtual Ward featuring protocolized teleconsultation of high-risk patients, use of a vital signs chatbot, supplemented by home visits where necessary. This study aims to evaluate the safety, outcomes and utilisation of the Virtual Ward as a scalable response to COVID-19 surges.MethodsThis is a retrospective cohort study of all patients admitted to the COVID Virtual Ward between 23 September to 9 November 2021. Patients were defined as “early discharge” if they were referred from inpatient COVID-19 wards and “admission avoidance” if they were referred directly from primary care or emergency services. Patient demographics, utilisation measures and clinical outcomes were extracted from the electronic health record system. The primary outcomes were escalation to hospital and mortality. Use of the vital signs chatbot was evaluated by examining compliance levels, need for automated reminders and alerts triggered. Patient experience was evaluated using data extracted from a quality improvement feedback form.Results238 patients were admitted to the COVID Virtual Ward from 23 September to 9 November, of whom 42% were male, 67.6% of Chinese ethnicity. 43.7% were over the age of 70, 20.5% were immunocompromised, and 36.6% were not fully vaccinated. 17.2% of patients were escalated to hospital and 2.1% of patients died. Patients who were escalated to hospital were more likely to be immunocompromised or to have a higher ISARIC 4C-Mortality Score. There were no missed deteriorations. All patients received teleconsults (median of 5 teleconsults per patient, IQR 3–7). 21.4% of patients received home visits. 77.7% of patients engaged with the vital signs chatbot, with a compliance rate of 84%. All patients would recommend the programme to others in their situation.ConclusionsVirtual Wards are a scalable, safe and patient-centered strategy to care for high risk COVID-19 patients at home.Trial RegistrationNA.

P273 Severity of colitis and clinical outcomes for patients admitted with acute UC in 2 large UK centres

Abstract Background Acute severe ulcerative colitis (ASUC) is a challenging complication of ulcerative colitis (UC) that can result in colectomy and even death. Management and recognition of the condition is based on criteria that have changed little since the 1950s (Truelove and Witts criteria). Patients may be admitted to hospital with acute colitis that does not meet criteria to be classed as severe. We hypothesised that such patients might be at risk of “over-management” if treated according to standard ASUC pathways. Methods We performed a retrospective review of inpatients managed for acute UC flares in two UK tertiary centres. We collected their baseline and outcome data. We assessed the proportion of patients meeting criteria for severe disease and compared outcomes between severe and non-severe groups. Results A total of 243 admissions for 200 unique patients were identified for analysis. A formal documentation of disease severity according to Truelove and Witts criteria was present in only 10/243 (4%). 121/243 (50%) met formal criteria for severe disease. Baseline demographic and disease characteristics were similar between patients with severe and non-severe disease (table-1). The use of rescue therapy was more common in the severe group (48% vs 34%, p=0.032). All other outcomes, including hospital length of stay, colectomy rates, and need for readmission were comparable (table-2). Conclusion Patients admitted for acute colitis may frequently not meet criteria for severe disease. It is possible that earlier discharge or admission avoidance may be possible for this group. Baseline demographics do not appear to identify patients with less severe symptoms who nonetheless get admitted. Although rescue therapy was less common for non-severe patients, other outcomes were comparable, including length of stay and colectomy rates. There is a risk that once admitted, non-severe patients may receive management according to standard algorithms for severe disease, risking overtreatment for a subgroup of patients.

1343 ADVANCE CARE PLANS (ACP) IN SECONDARY CARE: WHAT ARE THE PATIENT OUTCOMES FOLLOWING DISCHARGE FROM HOSPITAL WITH AN ACP?

Abstract Introduction Treatment escalation plans are discussed in hospital but not always communicated to community care on discharge, leading to avoidable admissions to hospital and hospital deaths which may be not what the patient wants. The project aimed to review what happened to patients discharged from hospital with an ACP over a 12-month period. Method Older person service (OPS) inpatients were identified for ACP discussions, using Clinical frailty score, presence of life limiting conditions, co-morbidities, significant decline. Over a 12-month period 155 ACP's were completed using the ACP document on the Trust electronic record (EPR), including the level of appropriate care and preference for location of on-going care. On discharge copies of the ACP were sent with the patient, to their GP and the ambulance service. EPR was used to review patients up to 12 months post discharge. Results Of patients with an ACP; the wish of all patients was to remain out of hospital and be cared for in the community; 63% were discharged to care home setting; 19% were readmitted as inpatients (43.7% Trust OPS/no ACP readmissions); 8% of patients died before discharge; 92% of patients who died after discharged, died out of hospital (47.5% Trust OPS/no ACP deaths); 25% were still alive at 12 months. The process of completing the ACP and communicating the ACP was found to be long and not user friendly with multiple steps and needed refining. Conclusion ACP's offer support to facilitate patient's wishes. The use of ACP's in secondary care benefits patients on discharge, it reduces readmissions and in-hospital deaths. The current ACP document is lengthy and requires simplifying. This has led to a work group to redevelop the ACP into a more user friendly/shareable document, which will encourage on-going use of ACP's and can be adopted throughout the Trust.

Opportunities and challenges of self-binding directives: A comparison of empirical research with stakeholders in three European countries.

Self-binding directives (SBDs) are psychiatric advance directives that include a clause in which mental health service users consent in advance to involuntary hospital admission and treatment under specified conditions. Medical ethicists and legal scholars identified various potential benefits of SBDs but have also raised ethical concerns. Until recently, little was known about the views of stakeholders on the opportunities and challenges of SBDs. This article aims to foster an international exchange on SBDs by comparing recent empirical findings on stakeholders' views on the opportunities and challenges of SBDs from Germany, the Netherlands, and the United Kingdom. Comparisons between the empirical findings were drawn using a structured expert consensus process. Findings converged on many points. Perceived opportunities of SBDs include promotion of autonomy, avoidance of personally defined harms, early intervention, reduction of admission duration, improvement of the therapeutic relationship, involvement of persons of trust, avoidance of involuntary hospital admission, addressing trauma, destigmatization of involuntary treatment, increase of professionals' confidence, and relief for proxy decision-makers. Perceived challenges include lack of awareness and knowledge, lack of support, undue influence, inaccessibility during crisis, lack of cross-agency coordination, problems of interpretation, difficulties in capacity assessment, restricted therapeutic flexibility, scarce resources, disappointment due to noncompliance, and outdated content. Stakeholders tended to focus on practical challenges and did not often raise fundamental ethical concerns. Stakeholders tend to see the implementation of SBDs as ethically desirable, provided that the associated challenges are addressed.

Physician perceptions of restrictive visitor policies during the COVID-19 pandemic: a qualitative study.

Little is understood of the consequences of restrictive visitor policies that were implemented in hospitals to minimize risk of infection during the COVID-19 pandemic. The objective of this study was to describe physician experiences with these policies and reflections of their effects. We conducted semistructured phone interviews from September 2020 to March 2021 with physicians practising in Ontario hospitals, recruited via professional networks and snowball sampling. We audio-recorded, transcribed and analyzed interviews to describe and interpret overarching themes by thematic analysis. We interviewed 21 physicians (5 intensivists, 5 internists, 11 specialists in palliative care). Four main thematic categories emerged, including provider, system, patient and caregiver effects. Provider-related factors included increased time and effort on communication with a need to establish limits; increased effort to develop rapport with caregivers; lack of caregiver input on patient care; the need to act as a caregiver surrogate; and the emotional toll of being a gatekeeper or advocate for visitors, exacerbated by lack of evidence for restrictions and inconsistent enforcement. System effects included the avoidance of hospital admission and decreased length of stay, leading to readmissions, increased deaths at home and avoidance of transfer to other facilities with similar policies. Patient-related factors included isolation and dying alone; lack of caregiver advocacy; and prioritization of visitor presence that, at times, resulted in a delay or withdrawal of aspects of care. Caregiver-related factors included inability to personally assess patient health, leading to poor understanding of patient status and challenging decision-making; perceived inadequate communication; difficulty accessing caregiver supports; and increased risk of complicated grief. Participants highlighted a disproportionate effect on older adults and people who did not speak English. Our study highlights substantial negative consequences of restrictive visitor policies, with heightened effects on older adults and people who did not speak English. Research is required to identify whether the benefits of visitor restrictions on infection control outweigh the numerous deleterious consequences to patients, families and care providers.

Atrial fibrillation virtual ward: reshaping the future of AF care

Abstract Background Atrial fibrillation (AF) hospital admissions represent significant AF related treatment costs nationally. In the year 2019–2020 our hospital reported 1,333 admissions with a primary diagnosis of AF, with a 10% annual increase. A virtual ambulatory AF ward providing multidisciplinary care with remote hospital-level monitoring could reshape the future model of AF management. Methods An AF virtual ward was implemented at our UK tertiary centre, as a proof-of-concept model of care. Patients admitted with a primary diagnosis of AF satisfying the AF virtual ward (AFVW) entry criteria (i.e., haemodynamically stable, HR &amp;lt;140 bpm with other acute conditions excluded) were given access to a single lead ECG recording device, a Bluetooth integrated blood pressure machine and pulse oximeter with instruction to record daily ECGs, blood pressure readings, oxygen saturations and fill an online AF symptom questionnaire via a smart phone or electronic tablet. Data were uploaded to an integrated digital platform for review by the clinical team who undertook twice daily virtual ward rounds. Medication adjustment was arranged through the hospital pharmacy. Data was collected prospectively for patients admitted to the AF virtual ward between 31 January and 11 March 2022. Outcomes included length of hospital stay, admission avoidance and re-admissions. Re-admission avoidance was assessed using the index admission criteria as a parameter for re-admission likelihood. Patients' satisfaction was assessed using the NHS family and friends' test (FFT). Results Over the 6-week period a total of 14 patients were enrolled. One patient was unable to be onboarded because of technology related anxiety with 13 patients onboarded to the virtual ward, 30.7% (n=4) did not have smart phones and were provided with electronic tablets. The age on admission was 64±10 years (mean±SD) with the oldest at 78 years of age. All patients were in AF with a mean heart rate of 122±24 bpm, and 38.5% (n=5) were discharged from the virtual ward in sinus rhythm. One patient was onboarded directly from pacemaker clinic and hence hospital admission was completely avoided, and 5 re-admissions were avoided for 3 patients. One patient required brief readmission due to persistent tachycardia requiring acute cardioversion. The FFT yielded 100% positive responses among patients. Conclusion This proof-of-concept is a first real world experience of a virtual ward for hospital patients with fast AF. It demonstrates a promising new telemedicine-based care model and with clear appetite among both patients and health professionals. This model of care has the potential to reduce the financial and backlog pressures caused by AF admissions without compromising patients' care or safety. Work is ongoing to further confirm the safety and cost-effectiveness upon further progress in a larger patient cohort. Funding Acknowledgement Type of funding sources: None.

Smartphone-based remote monitoring in chronic heart failure: patient &amp; clinician user experience, impact on patient engagement and quality of life

Abstract Background Heart failure with reduced ejection fraction (HFrEF) lowers patients' quality of life (QoL) [1]. Digital interventions such as ESC's “Heart Failure Matters” website aim to encourage patient-engagement &amp; self-management [2], which remain major challenges in HFrEF care. Although remote monitoring (RM) has been tested in HFrEF with inconclusive impact on prognosis [3], its impact on patients' experience and engagement is unclear [4]. Furthermore, the perspective of clinicians using RM technologies remains unknown. We present users' experience of Luscii, a novel smartphone-based RM platform enabling HFrEF patients to submit clinical measurements, symptoms, complete educational modules, &amp; communicate with HF specialist nurses (HFSNs). Purpose (I) To evaluate the usage-type &amp; user experience of patients and HFSNs. (II) To assess the impact of using the RM platform on self-reported QoL Methods A two-part retrospective analysis of HFrEF patients from our regional service using the RM platform: Part A: Thematic analysis of patient feedback provided via the platform and a focus group of six HFSNs. Part B: Scores for a locally-devised HF questionnaire (HFQ), depression (PHQ-9) &amp; anxiety (GAD-7) questionnaires were extracted from the RM platform at two timepoints: at on-boarding and 3 months after. Paired non-parametric tests were used to evaluate difference between median scores across the two time points. Results 83 patients (mean age 62 years; 27% female) used the RM platform between April and November 2021. 2 dropped out &amp; 2 died before 3 months. Part A: Patients and HFSNs exchanged information on many topics via the platform, including patient educational modules (Figure 1). Thematic analysis revealed positive and negative impacts with many overlapping subthemes between the two user groups (Figure 2). Part B: At 3 months there was no difference in HFQ score (19 vs. 18, p=0.57, maximum possible score = 50). PHQ-9 (3 vs. 3, p=0.48, maximum possible score = 27) and GAD-7 (5 vs. 3, p=0.54. maximum possible score = 21) scores were low at onboarding and follow-up. Conclusions This evaluation shows smartphone-based RM is feasible in HFrEF with good retention (2% drop-out rate over 3 months, albeit in a cohort with low baseline depression and anxiety levels). The platform serves as an integrated solution for symptom reporting, patient-clinician communication &amp; education. Positive impacts include patient engagement, convenience, admission avoidance &amp; medication optimisation, but there was no corresponding change in QoL scores in the short-term. We find potential pitfalls: information overload for patients &amp; increased workload for clinicians. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Sameer Zaman is supported by UK Research and Innovation [UKRI Centre for Doctoral Training in AI for Healthcare grant number EP/S023283/1].

Smartphone-based remote monitoring (RM) in chronic heart failure reduces emergency hospital attendances, unplanned admissions and secondary care costs: a retrospective cohort study

Abstract Background Despite effective therapies, the economic burden of heart failure with reduced ejection fraction (HFrEF) is driven by frequent hospital attendances [1]. Treatment optimisation and admission avoidance relies on frequent symptom review and monitoring of vital signs [2]. RM programmes aim to prevent admissions and improve system efficiency by enabling self-management [3]. Few studies evaluate the economic impact of RM in HFrEF, compared to real-world matched controls [4]. We compare hospital attendances and costs between patients using Luscii, a novel smartphone-based RM platform, and matched controls receiving usual care for 3 months. Purpose To assess the impact of RM on emergency department (ED) attendances, unplanned admissions and associated healthcare costs over 3 months. Methods A retrospective cohort study of new HFrEF referrals to our service was undertaken using the Discover dataset [5] for two cohorts (i) “RM group”: patients who used the RM platform for at least 3 months and (ii) “control group”: consecutive patients referred before the RM platform was available. The groups were matched 1:1 for age, sex, ethnicity, New York Heart Association grade and left ventricular ejection fraction. Medical co-morbidities, ED attendances, unplanned admissions and costs were extracted over 3 months from platform onboarding (RM group) or accepted referral (control group). Platform costs were added for the RM group. Differences between outcomes were analysed using t-tests, Kaplan-Meier event analysis and Cox's proportional hazard modelling. Results 146 patients (mean age 63 years; 23% female) were included in the analyses (73 “RM group”; 73 “Control group”). The groups were well-matched for all baseline characteristics except hypertension (p=0.03). Compared to the control group, after 3 months follow-up the RM group had significantly fewer ED attendances (p&amp;lt;0.01) and unplanned admissions (p&amp;lt;0.01). Accounting for RM platform costs, there was no difference between ED costs (p=0.42), but significantly lower unplanned admissions costs in the RM group (p=0.02) (Table 1). RM was protective against ED attendances (HR=0.43, p=0.02) and unplanned admissions (HR=0.26, p=0.02), which was sustained after controlling for hypertension (Table 1). Kaplan-Meier analyses found significantly lower probability of ED attendances (p=0.02) and unplanned admissions (p=0.01) in the RM group (Figure 1). Conclusions HFrEF patients with RM were half as likely to attend ED and approximately four times less likely to need short-term unplanned admissions. The economic benefit of RM is driven by lower unplanned admission costs; the cost benefit is equivocal at the ED stage. Participants were younger than the typical HFrEF cohort. RM use could free up valuable resources to enhance standard care for older patients who decline or are unable to use RM. Further evaluation is required of the long-term impact of RM and its effect on outpatient encounters and costs. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Discover data extraction and analyst time were funded by Astra Zeneca. Astra Zeneca did not have any input to study design, analyses or reporting.

Simultaneously reassuring and unsettling: a longitudinal qualitative study of community anticipatory medication prescribing for older patients

The prescription of injectable anticipatory medications is widely accepted by clinicians to be key in facilitating effective last-days-of-life symptom control. Community end-of-life care and admission avoidance is particularly strongly advocated for older patients. However, patient and informal caregiver views and experiences of anticipatory medication have been little studied to date. To understand older patients', informal caregivers' and clinicians' views and experiences of the prescribing and use of anticipatory medications. Qualitative study. Patients' homes and residential care homes. Purposive sample of six older patients, nine informal caregivers and six clinicians. Multi-perspective, longitudinal interview study based on 11 patient cases. Semi-structured interviews (n = 28) were analysed thematically. Three themes were identified: (i) living in the present whilst making plans: anticipatory medications were used by clinicians as a practical tool in planning for uncertainty, while patients and informal caregivers tried to concentrate on living in the present; (ii) anticipation of dying: it was rare for patients and informal caregivers to discuss explicitly the process and experience of dying with clinicians; and (iii) accessing timely care: the use of anticipatory medications generally helped symptom control. However, informal caregivers reported difficulties in persuading nurses to administer them to patients. Anticipatory medications are simultaneously reassuring and a source of unease to older patients and their informal caregivers. Prescriptions need careful discussion and tailoring to their preferences and experience. Nurses' decisions to administer medication should consider informal caregivers' insights into patient distress, especially when patients can no longer communicate their needs.

162 A REVIEW OF THE GENERAL PRACTITIONER REFERRALS TO A RAPID ACCESS FRAILTY ASSESSMENT UNIT IN A MODEL-3 HOSPITAL

Abstract Background The Rapid Access Frailty assessment unit (RAFAU) was set up in February 2021 and is run by a Raft (Rapid access frailty team). This is a dedicated multidisciplinary team in a model three hospital to review frail older patients to improve outcomes and admission avoidance. They review patients in the Emergency department as well as the assessment unit and on the ward for inpatient frailty reviews. The team is expanding as new roles are incorporated into the team and our service has evolved into a five day a week rapid access service. Methods We examined the number of GP referrals to our RAFU since May 2021 to March 2022 and the outcome of the review. Data was collected on all patients attending the RAFAU over an 11-month period. We selected all GP referrals which produced a cohort of 259 referrals to the unit. Results A total of 259 referrals were reviewed in RAFAU clinics. Mean age was 70-75 years old 60% were female, 40 % male. Reason for referral included: 38 % medical reasons, 32% cognitive issues, 18 % mobility ,7 % falls. Overall, 41% of referred patients had Clinical frailty scale score of 1-3, 16 % had a clinical frailty scale of 4, 8% clinical frailty scale of 5, 9% clinical frailty scale of 6, 5% clinical frailty scale of 7.The outcome of this cohort were as follows: 86 % needed further follow up, 9% were discharged and 1% admitted. Conclusion The RAFAU gives an alternative referral destination to GP’s for rapid review of frail older patients and thus potentially avoiding ED referral and admission. The vast majority of these referrals were for review of medical issues and cognitive assessment. The majority of patients required ongoing specialist frailty services and we hope to expand our service in the future.

306 GERIATRICIAN-LED COMPREHENSIVE GERIATRIC ASSESSMENT IN THE EMERGENCY DEPARTMENT: A COST-EFFECTIVE SERVICE APPROVED BY PATIENTS

Abstract Background Many older people are brought to the Emergency Department (ED) who do not require acute hospital admission but there are risks to these patients if this occurs. The Frailty Intervention Team (FIT) are an interdisciplinary team based in the ED including physiotherapy, occupational therapy, speech and language therapy, dietetics, pharmacy, advanced nurse practitioners, and a geriatric registrar and consultant. They assess frail older patients and suggest alternative care pathways to admission. We aimed to investigate the impact of FIT on admission avoidance, bed days saved and to obtain patient feedback on their experience. Methods Routinely collected data from May 2021 to April 2022 was reviewed retrospectively. An anonymous patient feedback questionnaire was posted to 40 patients randomised from the FIT worklist between January to May 2022. Results 2,025 Comprehensive Geriatric Assessments (CGA) were completed between May 2021 and April 2022. 38% percent of patients were discharged home, 45% of this number had follow-up arranged. 104 patients were transferred directly to an offsite bed, mostly rehabilitation. We estimate we avoided 51 admissions to the acute hospital per month, almost half of these were patients admitted to the hospital and, who we discharged to alternative care pathways or home. The average length of stay in April 2022 was 22 days – by avoiding 615 admissions between May 2021 and April 2022 we have saved 13,530 bed days at an estimated cost saving of almost €11 million. 15 completed questionnaires were returned. 73% were very satisfied with their experience. 87% felt the FIT team helped facilitate their discharge from ED. The main themes identified from open ended questions included thorough assessment, patient centred care and satisfaction with early intervention and discharge. Conclusion A Frailty Intervention Team is a cost effective and patient centred way of avoiding unnecessary admissions for older people presenting to the ED.

RUPTURED ACHILLES TENDON, A COMMON INJURY IN ATHLETES

Introduction: The Achilles tendon also named calcaneal tendon, can be subjected to tensile loads up to 10 times the body weight. It is located on the posterior aspect of the lower leg and is the thickest tendon. This tendon accounts for 20% of all large tendon injuries. There is discussion on which is the best treatment, among which the percutaneous repair of the Achilles tendon has risk of injuring the sural nerve. When a sharp, explosive and sudden force is exerted on the Achilles tendon, rupture or tears can occur.most of these ruptures occur during sports; however, sometimes it happens in non-athletes or sedentary people. Objective: To detail the current information related to Achilles tendon rupture and its treatment, as well as the different approach techniques. Methodology: A total of 29 articles were analyzed in this review, including review and original articles, as well as clinical cases, of which 19 bibliographies were used because the other 10 articles were not relevant for this study. The sources of information were PubMed, Google Scholar and Cochrane; the terms used to search for information in Spanish and English were: achilles tendon, Achilles tendon rupture, Achilles tendon treatment. Results: Achilles tendon rupture is more frequent in adults between the third and fifth decade of life. When it happens acutely they usually present sudden pain in the back of the leg accompanied by a snapping. This pathology can be falsely diagnosed as an ankle sprain in 20% to 25%. All patients require physical and orthopedic therapy and initial treatment consists of rest, elevation, pain control and functional orthopedic appliances. The advantages of non-surgical treatment are the avoidance of hospital admissions, wound complications and the risk of anesthesia. However, its main disadvantage lies in the increased risk of re-rupture, ranging up to 40%. Return to sporting life can be initiated 9 months after surgery as long as the patient is able to dorsiflex. Surgical treatment has a new rupture rate of 0.5% while non-surgical treatment has a rupture rate of approximately 40%. Conclusions: The Achilles tendon is formed by the fusion of the gastrocnemius and soleus muscles in its distal part. The contraction of these two muscles generates a force that causes plantar flexion of the foot. The Achilles tendon is innervated essentially by the sural nerve. Signs of the affected person may include swelling, bruising and/or a noticeable alteration in the tendon. Thompsons test can be used to better assess the picture. In athletics, basketball, diving, tennis, cycling, volleyball, gymnastics and others it is common to see tendon ruptures. If the patient presents with trauma to the lower leg, it is advisable to take X-rays in order to rule out fractures. The diagnosis can be confirmed with MRI or ultrasound. Surgical approach techniques for Achilles tendon repair include open, semi-open or limited open and percutaneous repair, although regardless of the technique of choice, restoration of tendon length must be ensured. Patients with significant medical comorbidities or those with relatively sedentary lifestyles are usually recommended to opt for non-surgical therapy. Surgical treatment mitigates the risk of re-rupture compared to conservative treatment; however, complication rates are much higher, and almost all athletes can return to physical activity without any limitations.

Smartphone-based remote monitoring in chronic heart failure: patient &amp; clinician user experience, impact on patient engagement and quality of life

Abstract Background Heart failure with reduced ejection fraction (HFrEF) lowers patients' quality of life (QoL) [1]. Digital interventions such as ESC's “Heart Failure Matters” website aim to encourage patient-engagement &amp; self-management [2], which remain major challenges in HFrEF care. Although remote monitoring (RM) has been tested in HFrEF with inconclusive impact on prognosis [3], its impact on patients' experience and engagement is unclear [4]. Furthermore, the perspective of clinicians using RM technologies remains unknown. We present users' experience of Luscii, a novel smartphone-based RM platform enabling HFrEF patients to submit clinical measurements, symptoms, complete educational modules, &amp; communicate with HF specialist nurses (HFSNs). Purpose (I) To evaluate the usage-type &amp; user experience of patients and HFSNs. (II) To assess the impact of using the RM platform on self-reported QoL Methods A two-part retrospective analysis of HFrEF patients from our regional service using the RM platform: Part A: Thematic analysis of patient feedback provided via the platform and a focus group of six HFSNs. Part B: Scores for a locally-devised HF questionnaire (HFQ), depression (PHQ-9) &amp; anxiety (GAD-7) questionnaires were extracted from the RM platform at two timepoints: at on-boarding and 3 months after. Paired non-parametric tests were used to evaluate difference between median scores across the two time points. Results 83 patients (mean age 62 years; 27% female) used the RM platform between April and November 2021. 2 dropped out &amp; 2 died before 3 months. Part A: Patients and HFSNs exchanged information on many topics via the platform, including patient educational modules (Figure 1). Thematic analysis revealed positive and negative impacts with many overlapping subthemes between the two user groups (Figure 2). Part B: At 3 months there was no difference in HFQ score (19 vs. 18, p=0.57, maximum possible score = 50). PHQ-9 (3 vs. 3, p=0.48, maximum possible score = 27) and GAD-7 (5 vs. 3, p=0.54. maximum possible score = 21) scores were low at onboarding and follow-up. Conclusions This evaluation shows smartphone-based RM is feasible in HFrEF with good retention (2% drop-out rate over 3 months, albeit in a cohort with low baseline depression and anxiety levels). The platform serves as an integrated solution for symptom reporting, patient-clinician communication &amp; education. Positive impacts include patient engagement, convenience, admission avoidance &amp; medication optimisation, but there was no corresponding change in QoL scores in the short-term. We find potential pitfalls: information overload for patients &amp; increased workload for clinicians. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Sameer Zaman is supported by UK Research and Innovation [UKRI Centre for Doctoral Training in AI for Healthcare grant number EP/S023283/1].

Atrial fibrillation virtual ward: reshaping the future of AF care

Abstract Background Atrial fibrillation (AF) hospital admissions represent significant AF related treatment costs nationally. In the year 2019–2020 our hospital reported 1,333 admissions with a primary diagnosis of AF, with a 10% annual increase. A virtual ambulatory AF ward providing multidisciplinary care with remote hospital-level monitoring could reshape the future model of AF management. Methods An AF virtual ward was implemented at our UK tertiary centre, as a proof-of-concept model of care. Patients admitted with a primary diagnosis of AF satisfying the AF virtual ward (AFVW) entry criteria (i.e., haemodynamically stable, HR &amp;lt;140 bpm with other acute conditions excluded) were given access to a single lead ECG recording device, a Bluetooth integrated blood pressure machine and pulse oximeter with instruction to record daily ECGs, blood pressure readings, oxygen saturations and fill an online AF symptom questionnaire via a smart phone or electronic tablet. Data were uploaded to an integrated digital platform for review by the clinical team who undertook twice daily virtual ward rounds. Medication adjustment was arranged through the hospital pharmacy. Data was collected prospectively for patients admitted to the AF virtual ward between 31 January and 11 March 2022. Outcomes included length of hospital stay, admission avoidance and re-admissions. Re-admission avoidance was assessed using the index admission criteria as a parameter for re-admission likelihood. Patients' satisfaction was assessed using the NHS family and friends' test (FFT). Results Over the 6-week period a total of 14 patients were enrolled. One patient was unable to be onboarded because of technology related anxiety with 13 patients onboarded to the virtual ward, 30.7% (n=4) did not have smart phones and were provided with electronic tablets. The age on admission was 64±10 years (mean±SD) with the oldest at 78 years of age. All patients were in AF with a mean heart rate of 122±24 bpm, and 38.5% (n=5) were discharged from the virtual ward in sinus rhythm. One patient was onboarded directly from pacemaker clinic and hence hospital admission was completely avoided, and 5 re-admissions were avoided for 3 patients. One patient required brief readmission due to persistent tachycardia requiring acute cardioversion. The FFT yielded 100% positive responses among patients. Conclusion This proof-of-concept is a first real world experience of a virtual ward for hospital patients with fast AF. It demonstrates a promising new telemedicine-based care model and with clear appetite among both patients and health professionals. This model of care has the potential to reduce the financial and backlog pressures caused by AF admissions without compromising patients' care or safety. Work is ongoing to further confirm the safety and cost-effectiveness upon further progress in a larger patient cohort. Funding Acknowledgement Type of funding sources: None.

Smartphone-based remote monitoring (RM) in chronic heart failure reduces emergency hospital attendances, unplanned admissions and secondary care costs: a retrospective cohort study

Abstract Background Despite effective therapies, the economic burden of heart failure with reduced ejection fraction (HFrEF) is driven by frequent hospital attendances [1]. Treatment optimisation and admission avoidance relies on frequent symptom review and monitoring of vital signs [2]. RM programmes aim to prevent admissions and improve system efficiency by enabling self-management [3]. Few studies evaluate the economic impact of RM in HFrEF, compared to real-world matched controls [4]. We compare hospital attendances and costs between patients using Luscii, a novel smartphone-based RM platform, and matched controls receiving usual care for 3 months. Purpose To assess the impact of RM on emergency department (ED) attendances, unplanned admissions and associated healthcare costs over 3 months. Methods A retrospective cohort study of new HFrEF referrals to our service was undertaken using the Discover dataset [5] for two cohorts (i) “RM group”: patients who used the RM platform for at least 3 months and (ii) “control group”: consecutive patients referred before the RM platform was available. The groups were matched 1:1 for age, sex, ethnicity, New York Heart Association grade and left ventricular ejection fraction. Medical co-morbidities, ED attendances, unplanned admissions and costs were extracted over 3 months from platform onboarding (RM group) or accepted referral (control group). Platform costs were added for the RM group. Differences between outcomes were analysed using t-tests, Kaplan-Meier event analysis and Cox's proportional hazard modelling. Results 146 patients (mean age 63 years; 23% female) were included in the analyses (73 “RM group”; 73 “Control group”). The groups were well-matched for all baseline characteristics except hypertension (p=0.03). Compared to the control group, after 3 months follow-up the RM group had significantly fewer ED attendances (p&amp;lt;0.01) and unplanned admissions (p&amp;lt;0.01). Accounting for RM platform costs, there was no difference between ED costs (p=0.42), but significantly lower unplanned admissions costs in the RM group (p=0.02) (Table 1). RM was protective against ED attendances (HR=0.43, p=0.02) and unplanned admissions (HR=0.26, p=0.02), which was sustained after controlling for hypertension (Table 1). Kaplan-Meier analyses found significantly lower probability of ED attendances (p=0.02) and unplanned admissions (p=0.01) in the RM group (Figure 1). Conclusions HFrEF patients with RM were half as likely to attend ED and approximately four times less likely to need short-term unplanned admissions. The economic benefit of RM is driven by lower unplanned admission costs; the cost benefit is equivocal at the ED stage. Participants were younger than the typical HFrEF cohort. RM use could free up valuable resources to enhance standard care for older patients who decline or are unable to use RM. Further evaluation is required of the long-term impact of RM and its effect on outpatient encounters and costs. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Discover data extraction and analyst time were funded by Astra Zeneca. Astra Zeneca did not have any input to study design, analyses or reporting.