Collateral Histories Research Articles

291 Improving the collateral history for older people admitted to hospital: the 6 Cs

Abstract Background Despite its central role in diagnostic formulation in unwell older adults, particularly those with memory problems, little scrutiny has been applied to Collateral History (CH) taking from how/when it should be performed, what information should be gathered and how it should be assimilated. This quality improvement project aims to address this by improving processes around collateral history taking for older patients. Methods The objectives of this project were to: (i) Establish information that should be included in the CH, (ii) Assess if this information is currently being collected and (iii) Use this to inform a proforma to assist with CH taking. Health-Care Professionals (HCPs) involved in the care of older people ranked information from CH in terms of relevance/importance (online survey). An audit was performed on a sample of consecutive patients aged ≥65 years admitted under the geriatric medicine service from 01/02/2023–17/02/2023, to assess compliance with and content of collateral histories against our HCP survey. Results 41 HCPs (13/41 (32%) medical, 6/41 (15%) nurse specialists, 15/41 (37%) physiotherapists/occupational therapists, 7/41 (17%) medical social workers) were surveyed. They ranked baseline and recent changes in cognition, function and mobility as key features of the CH. CHs were completed in 70% (35/50) of admissions (n = 50, mean 83 years, 42% documented cognitive impairment). Baseline cognition and function were documented in less than half of collateral histories, change in cognition in 18/35 (51%); change in function in 10/35 (29%). Baseline mobility was documented in 20/35 (57%); change in mobility in 9/35 (26%). Findings then informed an electronic patient record (EPR) proforma: ‘The 6 Cs of the Collateral History’ (Consent, Contact, Cognition, Change (Function/Mobility), Communication, Conclusion). Conclusion Compliance with, and content of, CHs vary widely. This QI project aims to address this by using an EPR proforma, co-designed by clinicians involved in the care of older people, to prompt/structure CH taking.

Hyperosmolar, hyperglycaemic state: a case study

Hyperosmolar, hyperglycaemic state (HHS) is diagnosed from a triad of symptoms: severe hyperglycaemia, profound dehydration and a high serum osmolality. Often, patients are admitted confused, which emphasises the importance of obtaining good collateral histories where possible. This article will explore a case study and examine the clinical symptoms, pathophysiology and evidence-based management of HSS to highlight how the assessment, timely diagnosis and treatment of HHS is a complex and challenging task.

Does simulation help medical support workers transition into working in the NHS?

A simulation-based programme was developed for the Medical Support Workers (MSW) within the Trust. The MSW role was created in response to the COVID-19 pandemic, providing an opportunity for doctors seeking GMC registration to gain clinical experience within a supervised NHS placement [1]. This project explored the MSWs’ perceptions and previous experience of simulation and their overall confidence working within the NHS before and after the teaching programme. The aim was to assess if simulation is a useful tool to help international medical graduates transition into working in the NHS. 29 MSWs (28 of whom were from Myanmar) worked in acute and medical specialties across the Trust, performing roles including: writing in medical notes, taking collateral histories, examining patients under supervision, procedures such as venepuncture and writing discharge summaries. Each MSW was invited to attend three training days between January and March 2022. We provided a programme incorporating medical and surgical simulation, communication workshops, and procedural skills, supported by human factors teaching. We delivered the sessions in our learning and research building, including our simulation suite. We collated data by sending out pre- and post-training surveys. There were 22 and 18 responses to the two initial surveys and 20 responses to the post-training survey. 44% had prior experience of clinical simulation and only 9% had previous experience working as a doctor in the NHS. On further analysis, 50% felt either quite unconfident, or neither confident or unconfident working in the NHS. A minority felt confident dealing with medical emergencies (18%) and surgical emergencies (13%) and with their communication (32%) and leadership skills (23%). In the post-simulation feedback, 100% reported that simulation was a useful method to help doctors transition into working in the NHS and felt it improved their confidence in the workplace. Furthermore, 100% stated that the simulation sessions had changed their clinical practice and addressed their learning needs. The participants reported that the sessions had improved their stepwise approach to emergencies (100%), communication (95%), teamwork (100%), leadership (70%), and decision-making skills (95%). This project demonstrated that simulation is a popular and useful educational resource in helping improve international doctors’ confidence when transitioning into working in the NHS. Given that 100% of our participants wanted further simulation sessions, our Trust plans to employ a dedicated MSW simulation fellow to support further cohorts. 1. Temporary Medical Support Worker (MSW) Secondary Care – Job description and person specification. NHS England and NHS Improvement.

1049 IMPROVING TELEPHONE COMMUNICATION WITH FAMILIES ON A BUSY MEDICAL WARD DURING THE PANDEMIC

Abstract During the pandemic it became critical to reduce visiting to only very specific situations. This resulted in an increase of complaints where a lack of communication from the ward had been recognised as a theme, in spite of the fact that many doctors spent a great deal of time providing updates over the phone to patient’s families. It was noted there were a number of inefficiencies with respect to communicating with families; some families were being contacted repeatedly whereas others were struggling to get in touch. Chronic staffing shortages were also a barrier to effective and timely communication. Qualitative data collected via an online survey demonstrated that junior doctors valued the importance of communicating with families, particularly to provide clinical updates or obtain collateral histories, but found that the extra burden created by the pandemic resulted in far less time to do this efficiently and often resulted in time management difficulties. We introduced a strategy, by way of a magnetic communication board, that provided a flexible, at-a-glance method of ensuring all families had received regular updates from the medical team and collateral histories had been obtained for all relevant patients. We collected weekly data regarding the number of interactions between the medical team and patient relatives’ as a percentage of the total number of bed spaces. An overall improvement was noted: 67% pre-intervention to 76% post, with a maximum of 88% during one particularly successful week. We also were able to demonstrate an increase in ReSPECT form completion (from 40% to 65%). The introduction of an organisational tool such as our communication board resulted in improved patient and relatives’ satisfaction; and an improvement in team performance and overall time management. We are now aiming to build on this and roll it out during the next wave of the pandemic.

793 COLLATERAL HISTORY IN PATIENTS WITH CONFUSION

Abstract Introduction The aims of the project were to intervene early on admission, by taking a collateral history for patients with confusion; to improve the quality and detail of collateral history being taken to better establish certain clinically important specks of information. These include triggers for delirium, the patient’s baseline cognition, any patterns in the change of a patient’s cognition to help determine if a patient was displaying aspects of a certain type of dementia prior to admission, baseline mobility and housing situation, baseline continence, history of substance misuse and alcohol etc. Ultimately, this project aims to identify next of kin from which collateral history can be obtained, but also to establish a firm communication platform to facilitate future discussions on behalf of patients undergoing delirium. This will ultimately, improve care but also making sure family members are involved early on in admission, exploring their ideas, concerns, and expectations. Methods We created a collateral history template booklet that was introduced to a geriatric ward. Specific parameters were set and measured, pre-intervention and post-intervention. A second round of post-intervention data collection was performed with an improved collateral history sheet outlook. We measured the outcome of 22 collateral histories for each round. Results We found that in both rounds, post intervention, there was an improved outcome compared to pre-intervention in almost all the parameters that were measured. For example, in 100% of the collateral histories there was documentation of the patient’s baseline concentrations and attention, issues with orientation, issues with expressive and receptive dysphasia and the main concerns of the next of kin, any problems with executive functioning and the baseline functional status of the patients. Conclusion The collateral history, both improved the overall quality and the quantity of the information gathered in patients with confusion and, contributed to a structured management.

The migraine postdrome: Spontaneous and triggered phenotypes.

BackgroundNon-painful symptoms in migraine following headache resolution can last up to days. Studying the postdrome is important to appreciate the morbidity associated with migraine.MethodsFifty-three subjects (n = 53) with migraine were studied in an experimental setting, collecting historical phenotypic information on the postdrome in their spontaneous attacks, and also associated with nitroglycerin-triggered attacks, while being observed prospectively. In a separate headache clinic-based cohort of migraineurs (n = 42), who were age and sex-matched to the experimental group, the same phenotypic data were extracted from their clinic records. Spontaneous and nitroglycerin-triggered attack phenotypes, and experimental and clinical cohort phenotypes were compared using agreement analysis.ResultsIn the experimental group, 100% had a postdrome with their triggered attack, while 98% reported a postdrome in their spontaneous attacks. In the clinical group, 79% had reported a postdrome. In the experimental group, there was good agreement between spontaneous and nitroglycerin-triggered tiredness, hunger, mood change, sensory sensitivities and vertigo and with similarity in premonitory and postdrome phenotypes experienced in the same individual.ConclusionsThe migraine postdrome is common and symptomatically similar to the premonitory phase. The nitroglycerin model and migraine abortive agents can be used to study the postdrome experimentally. Systematic questioning of symptoms, as well as collateral histories from direct observers of migraine attacks, are likely to enhance symptomatic capture of the migraine postdrome, and aid understanding of attack mediation, abortion and neurobiology.

63 Quality Improvement Project: Should We be Doing More or Less Ct Head Scans in the Health Care of Older People Department?

Abstract Introduction Older people are likely to have more CT head scans given their multiple co- morbidities, being on anticoagulants, and increased falls. The aims of this quality improvement project (QIP) were to identify the number of patients who had CT head scan, the reason/indication of it, the number of patients who had new finding/s on it, actions taken on new findings, and whether the management plan was altered because of the CT scan. Methods Medical notes and CT head scan reports of all patients admitted to the Health Care of Older People department from April to September 2018 were reviewed to evaluate the indications of CT head scans, new findings, and management plans following the findings. Results 461 (10.7%) out of the 4323 patients discharged from the healthcare of older people department during April to September 2018 had CT head scans during admission. Frequent indications for CT head scans included delirium, falls and head injury. Only 46 (9.9%) patients had new finding/s on the CT head scan, and action was taken on 26 (56.5%) of these patients. The CT head scan changed the management plan of only 17 (3.6%) patients. Please see Table for more details. Conclusions By using our clinical judgement, following NICE guidelines on head injuries, educating our colleagues on the criteria for requesting a CT head scan, taking collateral histories about patients’ cognition and ascertaining the mechanism of fall, we can lessen the financial burden on the NHS and minimise the radiation exposure to our patients.

281 Collateral Damage: The Cost of Failing to Take a Comprehensive Collateral History for Older Adults with Cognitive Impairment

Abstract Background Age-related syndromes of cognitive impairment, including delirium and dementia, are becoming more prevalent in our hospitals. Patients with cognitive impairment are often unable to provide information relating to their pre-morbid cognition and function as well as their admission diagnosis. Such information is essential to correctly identifying delirium and dementia, as well as making an accurate diagnosis and planning appropriate treatment. It is the standard of care recommended by both the Irish National Audit of Dementia 2014 and the UK National Audit of Dementia Care 2017 that a collateral history is obtained. Methods We reviewed the medical notes and conducted brief structured interviews with nursing staff for 100 medical inpatients aged ≥75. Results Only 44% of patients with cognitive impairment had a collateral history. Half of patients described as having dementia did not have any further detail on the severity of dementia documented. 80% of collateral histories were sourced by the admitting NCHD; if the collateral history was not obtained on admission, it was unlikely to be obtained at all. Among those for whom a collateral history was obtained, the level of detail regarding pre-morbid cognition, function, mobility and continence was sparse. The most common informant was the patient’s son or daughter (66%), followed by spouse (16%). Only 13% of patients had formal cognitive testing. Conclusion Acute illness characteristically causes significant impairments in cognition and function in frail older patients. Identifying and reversing these impairments is impossible without a comprehensive collateral history. It is alarming that such an essential component of clinical assessment is so often disregarded and highlights the lack of awareness from clinicians of the importance of collateral history in the management of patients with dementia and delirium. This must be emphasised in both undergraduate and postgraduate teaching. An appropriate admission proforma would also promote competent collateral history taking.

Cognitive assessment of older adults in general practice: the collateral history.

The collateral (or informant) history is a key component in the assessment of older adults presenting with a memory problem or concern over cognition. Despite this, it rarely features in medical literature and academic curricula. Its role in general practice has never been assessed. The aim of this study is to assess the role of the collateral history in the investigation of cognitive impairment in general practice. An online survey distributed to three nationally representative cohorts of GPs in Ireland (n = 692). Ninety-five (14%; 52.2% male) responded. Nearly all (87%; 83/95) indicate that it is most often a family member who brings possible cognitive impairment to the attention of their GP. The vast majority obtain a collateral history in > 90% of cases (72.6%; 69/95) and rate it very useful in their clinical assessment of cognition. GPs report the collateral history as readily available and rarely refused, with the general practice environment well-suited to obtaining collateral histories. A small minority routinely use the GPCOG informant section (3.2%; 3/95). Nearly all (92.6%; 88/95) report having received no training in obtaining collateral histories with most (79%; 75/95) welcoming of further training in this area. Despite recognition of the utility and importance of the collateral history, the vast majority of GPs report having never received training in obtaining one and do not use structured tools to guide their interview. Further emphasis on the informant history as a distinct clinical entity on medical curricula and increasing emphasis on the availability of structured informant tools are warranted.

Depression Case Finding in Individuals with Dementia: A Systematic Review and Meta‐Analysis

To compare the diagnostic accuracy of depression case finding tools with a criterion standard in the outpatient setting among adults with dementia. Systematic review and meta-analysis. Studies of older outpatients with dementia. Elderly outpatients (clinic and long-term care) with dementia (N = 3,035). Prevalence of major depression and diagnostic accuracy measures including sensitivity, specificity, and likelihood ratios. From the 11,539 citations, 20 studies were included for qualitative synthesis and 15 for a meta-analysis. Tools included were the Montgomery Åsberg Depression Rating Scale, Cornell Scale for Depression in Dementia (CSDD), Geriatric Depression Scale (GDS), Center for Epidemiologic Studies Depression Scale (CES-D), Hamilton Depression Rating Scale (HDRS), Single Question, Nijmegen Observer-Rated Depression Scale, and Even Briefer Assessment Scale-Depression. The pooled prevalence of depression in individuals with dementia was 30.3% (95% CI = 22.1-38.5). The average age was 75.2 (95% CI = 71.7-78.7), and mean Mini-Mental State Examination scores ranged from 11.2 to 24. The diagnostic accuracy of the individual tools was pooled for the best-reported cutoffs and for each cutoff, if available. The CSDD had a sensitivity of 0.84 (95% CI = 0.73-0.91) and a specificity of 0.80 (95% CI = 0.65-0.90), the 30-item GDS (GDS-30) had a sensitivity of 0.62 (95% CI = 0.45-0.76) and a specificity 0.81 (95% CI = 0.75-0.85), and the HDRS had a sensitivity of 0.86 (95% CI = 0.63-0.96) and a specificity of 0.84 (95% CI = 0.76-0.90). Summary statistics for all tools across best-reported cutoffs had significant heterogeneity. There are many validated tools for the detection of depression in individuals with dementia. Tools that incorporate a physician interview with patient and collateral histories, the CSDD and HDRS, have higher sensitivities, which would ensure fewer false-negatives.

Is National Emergency Access Target dumbing down emergency physicians?

Is National Emergency Access Target dumbing down emergency physicians?

Understanding attention deficit disorder: a neuroscience prospective.

Today’s ready access to electronic devices and the internet often substitute for social interaction. Such situation, if it starts in early childhood, in certain vulnerable individuals, who crave immediate rewards, can decrease the ability to maintain prolonged attention (1) and tolerate delayed gratification, thus reinforcing future addictive behaviors (2). Once established, these behaviors, such as attention deficit hyperactivity disorder (ADHD), may persist into adulthood. ADHD is one of the most common reasons for referring children to mental health facilities. Generally, parents seek professional help for their children after the school suggests that their child has difficulties. These difficulties may be related to academic performance, behavior, or both. Research data support the idea that children with attention deficit disorder often come from families with attention deficit in one or both parents (3). Very recent data indicate a significant genetic predisposition for this disorder. Seventy percent of children who have this disorder will have the disorder as teenagers, and about 40%-60% will still have the disorder as adults, and although genetic studies have not isolated a gene for ADHD, there may be several genes contributing to the vulnerability for developing this disorder. For example, twin studies have shown a significant heritability for ADHD (4) as high as 76%. In addition, the parents and siblings of children with ADHD have an ADHD diagnostic probability 4-5 times higher than the general population, and boys are more vulnerable than girls (5). Based on these data, it might appear that ADHD is easily diagnosed and, thus, simple to treat, but we still must question the methods and criteria used for diagnosing ADHD. Currently, clinical interviews and collateral histories from parents and teachers drive the standards. Only occasionally do we use objective assessments, such as continuous performance tasks and neuropsychological assessments, to evaluate whether or not a child can sustain attention, and whether their deficits lie in either or both auditory and visual domains. Various factors may play a role in sustaining attention. These may include: motivation, concurrent anxiety, lack of sleep, low blood glucose, medication, and family collaboration (6). Clinicians consider and evaluate three major symptom groups for diagnosing ADHD: inattention, hyperactivity, and impulsivity. Each category describes particular symptoms; for example, inattention may involve an inability to finish tasks, organize, and sustain efforts as well as forgetfulness and distractibility. Hyperactivity is defined as being fidgety, inability to sit still, and motoric hyperactivity – excessive running, climbing, and moving. Impulsivity involves excessive talking, answering without thinking, inability to wait one’s turn, interrupting, and so on. Both the DSM IV and the ICD 10 provide guidelines for the frequency and duration of the symptoms in these diagnostic categories, and both generally agree on the necessary number of symptoms before someone receives the diagnosis of ADHD. Nevertheless, it should be noted that these symptoms may be defined and scored by individuals that are untrained in this process. Therefore, we need to question the reliability and validity of such unidimensional data.

Paraoesophageal splenosis: An unusual differential of mediastinal soft tissue deposits.

Ectopic splenic tissue can present as accessory spleens and splenosis. While accessory spleens are congenital and more common; splenosis occurs as a result of implantation of splenic tissue as a result of trauma or iatrogenic injury. Only up to 40 intrathoracic splenosis have been reported in the English language literature to date. Here we discuss a case in which Para oesophageal pre-aortic ectopic splenic tissue was identified through radionuclide imaging 20 years after splenic rupture in a 44-year-old male for work up of epigastric pain.Splenosis should be considered as differential diagnosis in all previously splenectomised patients who present with unexplained masses on imaging. Early diagnoses with preoperative non-invasive radionucleotide scanning with collateral histories can prevent unnecessary surgery and reduce expensive and invasive investigations.

Mutual guarantee institutions and small business finance

A large body of literature has shown that small firms experience difficulties in accessing the credit market due to informational asymmetries. Banks can overcome these asymmetries through relationship lending, or at least mitigate their effects by asking for collateral. Small firms, especially if they are young, have little collateral and short credit histories, and thus may find it difficult to raise funds from banks. In this paper, we show that even in this case, small firms may improve their borrowing capacity by joining Mutual Guarantee Institutions (MGI). Our empirical analysis shows that small firms affiliated to MGIs pay less for credit compared with similar firms. We obtain this result for interest rates charged on loan contracts which are not backed by mutual guarantees. We then argue that our findings are consistent with the view that MGIs are better at screening and monitoring opaque borrowers than banks are. Thus, banks benefit from the willingness of MGIs to post collateral since this implies that firms are better screened and monitored.

Mutual Guarantee Institutions and Small Business Finance

A large body of literature has shown that small firms experience difficulties in accessing the credit market due to informational asymmetries. Banks can overcome these asymmetries through relationship lending, or at least mitigate their effects by asking for collateral. Small firms, especially if they are young, have little collateral and short credit histories, and thus may find it difficult to raise funds from banks. In this paper, we show that even in this case, small firms may improve their borrowing capacity by joining mutual guarantee institutions (MGIs). Our empirical analysis shows that small firms affiliated with MGIs pay less for credit compared with similar firms which are not MGI members. We obtain this result for interest rates charged on loan contracts which are not backed by mutual guarantees. We then argue that our findings are consistent with the view that MGIs are better than banks at screening and monitoring opaque borrowers. Thus, banks benefit from the willingness of MGIs to post collateral since it implies that firms are better screened and monitored.