Discharge Letters Research Articles

Intracranial venous stenting for idiopathic intracranial hypertension.

There is increasing evidence in the literature to support venous sinus stenting in patients with idiopathic intracranial hypertension who fail first-line therapy. Venous sinus stenting is a safe and successful technique compared with cerebrospinal fluid diversion procedures. This study examines the clinical outcomes of patients post intracranial venous stenting for intracranial hypertension across three tertiary hospitals in Western Australia. A retrospective analysis was performed on 83 consecutive patients treated with intracranial venous stenting for IIH at three tertiary hospitals from October 2013 to March 2020. Data were collected from outpatient clinic letters, electronic discharge letters, electronic radiological imaging and procedural reports. 89.2% patients were able to cease Acetazolomide post stenting. 78.3% patients reported resolution of headaches. 84.3% patients demonstrated resolution of their papilloedema. 91.6% patients demonstrated improvement of their visual acuity. Compared with a recent meta-analysis by Satti and Chaudry in 2015, our results demonstrated a higher technical success rate and lower complication rates. Our study findings support the paradigm shift from CSF diversion procedures to venous sinus stenting in patients with IIH who fail first-line therapy. Venous sinus stenting has a high technical success rate and significantly lower complication rates than other invasive treatments.

Junior Doctors’ Education and Training facilitated by Quality Improvement Project

Quality improvement projects are vital to improve and maintain the quality of care. Focused education and training is one of the most effective interventions to improve quality. We used the quality improvement cycle also called the Shewhart cycles protocol to objectively identify areas requiring focused education and training and measure the effectiveness of our education strategies through the completion of the quality improvement cycle. This project comprised two phases. In the first phase discharge summaries of surgical patients in a single surgical ward for two weeks were reviewed. Data regarding the accuracy and appropriateness of essential components of discharge summaries were collected. The education session was arranged for doctors involved in making discharge letters. Considerable (Accuracy / Appropriateness <75%) deficiencies were identified in 7 out of 10 components of the discharge summaries. Most of the doctors felt the educational session was beneficial. There was no component of the discharge letters with considerable deficiencies in the second phase. Significant improvement was seen in 6 out of 7 components which were identified to be deficient. We conclude that focused education and training of healthcare staff facilitated by the implementation of the Shewhart cycle is an effective way of quality improvement.

Hospital-acquired infections surveillance and prevention: using Natural Language Processing to analyze unstructured text of hospital discharge letters for surgical site infections identification and risk-stratification.

Hospital-acquired infections surveillance and prevention: using Natural Language Processing to analyze unstructured text of hospital discharge letters for surgical site infections identification and risk-stratification.

Prevalence of gestational diabetes and recourse to postpartum oral glucose tolerance test in the Autonomous Province of Trento (Italy)

ObjectiveThe occurrence of gestational diabetes (GDM) is increasing worldwide, and such a diagnosis is important for women's health beyond pregnancy. Therefore, many guidelines suggest the re-evaluation of glucose tolerance with a postpartum oral glucose tolerance test (OGTT) in women with GDM. This study reports the prevalence of GDM and the use of a postpartum OGTT in women assisted at maternity units in the Autonomous Province of Trento in the years 2017–2018, investigating the socio-demographic and health-care variables that can facilitate access to the test. Study designFor the diagnosis of GDM, the International Association of Diabetes and Pregnancy Study Group criteria were used. The Birth Assistance Certificate and the Hospital Information System were used to retrieve clinical and socio-demographic data. Univariate and multivariate analyses were performed to evaluate the stratification of the use of a postpartum OGTT. ResultsIn total, 8,308 pregnant women were assisted at the maternity units in Trento. There were 532 recorded cases of GDM (266 cases per year) and the overall average prevalence was 6.4 % (95 % CI, 5.90–6.90), 4.9 % of whom were Italian (95 % CI, 4.38–5.42) and 10.4 %, foreigners (95 % CI, 9.13–11.67).135 women diagnosed with GDM and residing in Trento out of 513 were evaluated using a postpartum OGTT (26.3%, CI 95% 22.50–30.10), with pathological results in 61 cases (45.2%). In the multivariate analyses, insulin therapy during pregnancy, delivery at a third-level birth point, and a discharge letter informing of the presence of GDM and of the need for a postpartum OGTT were independent factors associated with the probability of carrying out a postpartum OGTT. ConclusionsThe prevalence of GDM in our study is lower than in previous Italian studies; however, it is consistent with European data. The proportion of women who were assessed using the postpartum OGTT is lower than that reported by previous studies. The health-care factors seem predominant among the socio-demographic characteristics of the cases in influencing access to the test. The awareness of women, the sharing of guidelines among the different sectors of the health system, and an optimal management of the discharge from the birth point are critical in ensuring an optimal follow-up in women with GDM.

731 MULTICENTRE OBSERVATIONAL REGISTRY OF PATIENTS HOSPITALIZED FOR HEART FAILURE AND REAL-LIFE ADHERENCE TO INTERNATIONAL GUIDELINES FOR THE MANAGEMENT OF PATIENTS WITH ACUTE AND CHRONIC HEART FAILURE. THE REAL-HF REGISTRY

Abstract Purpose The Multicentre observational REgistry of patients hospitalized for heart failure and reAL-life adherence to international guidelines for the management of patients with acute and chronic Heart Failure (REAL-HF) aims to provide a comprehensive overview of hospital management of HF patients in Italy. Methods The registry involves 11 cardiology centers from seven Italian regions, including all adult patients hospitalized for HF in the period 2020-2026. Data are derived from hospital discharge letters and electronic records. Patients are included in the registry based on Diagnosis Related Groups codes. Results This preliminary analysis included 1600 patients hospitalized for HF in 2020 in two Italian tertiary university hospitals. Males were 851(53%) with a median age of 81(71-87) years. Less than one-third of the patients (n=461[29%]) was hospitalized in a cardiology unit, while almost half of the patients (n=783[49%]) was admitted to an internal medicine ward. Median hospital length of stay was 9(6-14) days. Readmission rates were 9% and 29% at 30 days and within the same year, respectively. In-hospital mortality was 9%, while 28% of the patients died within the same year. According to HF categories, 501(31%) patients were diagnosed as having HFrEF, 193(12%) mildly reduced ejection fraction (HFmrEF) and 689(43%) preserved ejection fraction (HFpEF). Median left ventricular EF was 49%(35-55%) and was significantly lower in patients with HFrEF (30%[25-35%]) compared to those with HFmrEF (45%[43-45%]) and HFpEF (55%[55-60%]) – p<0.001. Coronary artery disease proved to be the leading cause (n=460[29%]) of HF. Atrial fibrillation was highly prevalent (history -13%; during hospitalization -37%). Arterial hypertension was the most prevalent (71%) cardiovascular risk factor. Chronic kidney disease (51%) and chronic obstructive pulmonary disease (27%) were frequent comorbidities. Apparently, COVID-19 had a low impact, being present in only 3% of patients hospitalized for HF in 2020 at both centers. At discharge, 56% of patients were treated with angiotensin-converting enzyme inhibitors–ACEi (n=490[34%]), angiotensin receptor blockers–ARB (n=221[15%]) or angiotensin-neprilysin inhibitors–ARNi (n=100[7%]), 67%(n=964) with beta-blockers, while mineralocorticoid receptor antagonists–MRAs were prescribed for 56%(n=809) of patients. Loop diuretics were frequently prescribed (89%). When we considered patients with HFrEF, we found that only 69% were treated with ACEi/ARB/ARNi, 82% with a beta-blocker, and 67% with MRAs. Only 48% (n=240) were treated with all three of the above-mentioned classes of drugs. Among patients with HFrEF, only 5% had an implantable cardioverter defibrillator, and only 4% were treated with cardiac resynchronization therapy. Patients hospitalized in wards other than cardiology were older (83vs70 years, p<0.0001), more frequently females (52%vs44%, p<0.001), and with HFpEF (51%vs24%, p<0.0001). In-hospital mortality and death within the same year resulted significantly lower in patients hospitalized in cardiology units (5%vs11% - p<0.001, and 17%vs32% - p<0.001). Overall, drugs indicated in HF were less frequently prescribed in patients hospitalized in non-specialist cardiac units. Conclusions Preliminary data from the multicentre REAL-HF registry confirm that HF constitutes a clinical issue. Adherence to the guidelines is still inadequate and this may impact on patients’ outcomes. Moreover, the significant differences in terms of patients’ profiles might further increase the gap between highly specialized cardiology units and internal medicine departments.

Timing and causes of death after endovascular thrombectomy in patients with acute ischemic stroke.

Endovascular thrombectomy (EVT) increases the chance of good functional outcome after ischemic stroke caused by a large vessel occlusion, but the risk of death in the first 90 days is still considerable. We assessed the causes, timing and risk factors of death after EVT to aid future studies aiming to reduce mortality. We used data from the MR CLEAN Registry, a prospective, multicenter, observational cohort study of patients treated with EVT in the Netherlands between March 2014, and November 2017. We assessed causes and timing of death and risk factors for death in the first 90 days after treatment. Causes and timing of death were determined by reviewing serious adverse event forms, discharge letters, or other written clinical information. Risk factors for death were determined with multivariable logistic regression. Of 3180 patients treated with EVT, 863 (27.1%) died in the first 90 days. The most common causes of death were pneumonia (215 patients, 26.2%), intracranial hemorrhage (142 patients, 17.3%), withdrawal of life-sustaining treatment because of the initial stroke (110 patients, 13.4%) and space-occupying edema (101 patients, 12.3%). In total, 448 patients (52% of all deaths) died in the first week, with intracranial hemorrhage as most frequent cause. The strongest risk factors for death were hyperglycemia and functional dependency before the stroke and severe neurological deficit at 24-48 h after treatment. When EVT fails to decrease the initial neurological deficit, strategies to prevent complications like pneumonia and intracranial hemorrhage after EVT could improve survival, as these are often the cause of death.

Obesity screening in the pediatric emergency department – A missed opportunity?

ObjectivesThere is a low rate of body mass index measurements and obesity screening in primary pediatric care. Pediatric emergency department (PED) visits, with their large volumes and routine weight measurements, provide a unique opportunity to identify and address obesity. The study objectives were to examine the rate of addressing obesity in the PED and to identify its predicting factors. MethodsFrom electronic medical records of PED visits during 2010–2019, we extracted data on age, gender, weight, time, listed diagnoses, and discharge texts. The primary outcome was a listed diagnosis of “obesity” on discharge letters of children with obesity. Secondary outcomes were addressing weight in the discharge letter and written recommendations for obesity-related treatment. Mixed models were used to test for associations between each of the three outcomes and patient/visit characteristics. ResultsThere were 150,250 PED visits by 88,253 different children and adolescents. Obesity was found in 10,691 children (12.1%). Among these, listed “obesity” diagnosis was present in only 240 (1.5%) visits. Text addressing overweight/obesity was recorded in 721 (4.4%) visits, and weight-related recommendations were documented in 716 (4.4%) visits. “Obesity” was documented in females more often than in males, in older children, in children with higher weights, and in visits conducted during the mornings. ConclusionsThe rate of obesity diagnosis in the PED was extremely low, hence the potential screening ability of the PED in this matter is highly under-utilized. PEDs could increase the recognition of obesity, thus assisting in the global efforts in tackling this disease.

Introduction of the Discharge Medicines Service (DMS) at acute NHS trust, does this go far enough?

Abstract Introduction The Discharge Medicines Service (DMS) is one of several initiatives being implemented as part of the NHS 5-year plan's second year to relieve the load on hospital Accident and Emergency (A&E) departments. The DMS service specification states that patients who are considered to be at risk of medication-related harm should be electronically referred by the NHS Trust to a pharmacy for assistance with their medications within 24-48 hours of being discharged from the hospital. NHS England and NHS Improvement made available £1.2 million to ensure NHS trusts have appropriate software and functionality to send referrals to community pharmacy, but the funding is not available to private providers responsible for community hospital services. However, for the DMS service to strengthen and improve medicine safety across the NHS, there is a need to involve community hospital services run by private providers. Aim The aim of this study was to investigate the medicines related risk for patients discharged from Caterham Dene Hospital (CDH), a community hospital service. Methods A retrospective analysis of patient discharge summaries was carried out to determine whether there were changes in the patient’s medication prior to being discharged from East Surrey Hospital (ESH) to CDH and then to their home. The medical records of (N=183) patients who were admitted to CDH from ESH between 1st June 2021 - 31st December 2021 were identified. 22 patients who were re-admitted to ESH through A&E and 2 patients whose discharge letter could not be found in their medical record or had missing information were excluded. Patients who were discharged to another care setting, e.g. a care home, were also excluded from this study. A data collection form was used, and the data were transferred to Microsoft Excel for descriptive statistical analysis. As a service evaluation, ethical approval was not required. Results A total of 159 patients’ medical records and discharge summaries were analysed, of whom 97% of patients had changes in their medication after admission to CDH. The most frequent changes were either having medication stopped because it was no longer required, or medication started due to new diagnosis. The top two commonly identified drug classes are laxatives and opioids. 40% of all medicines that were changed were appropriate for DMS referral on discharge from CDH. Discussion/Conclusion Although a small-scale study, the findings demonstrate that it is important for private providers of community hospital services, such as First Community, to be included to deliver the DMS referral service. Further investigation is recommended to explore whether similar results would be achieved in other community hospital services run by private providers. In response to the discharge data shared, Surrey Heartland Integrated Care System made available funds to roll out the DMS service to CDH. First Community is the only private provider currently delivering the DMS service and between mid-June and July 2022 a total of 10 patients have been referred.

Atrial fibrillation and anticoagulation are associated with hospitalisations in patients with end-stage kidney disease on haemodialysis: a prospective population-based cohort study

BackgroundPatients with end-stage kidney disease on haemodialysis suffer from frequent complications requiring hospitalisation. Atrial fibrillation is a burdensome comorbidity amongst patients on haemodialysis. We aimed to assess frequency, reasons, and duration of hospitalisations in haemodialysis patients and their association with atrial fibrillation and anticoagulation.MethodsPrevalent patients with end-stage kidney disease on haemodialysis were recruited into a prospective cohort study and observed for a median observation time of 3.4 years. Hospitalisations were recorded from discharge letters, medical records, and patient interviews. The association of atrial fibrillation, anticoagulation, and time-in-therapeutic range of vitamin K antagonist treatment with hospitalisations was analysed using negative binomial regression.ResultsOut of 625 patients, 238 (38.1%) had atrial fibrillation. Median number of hospitalisations per patient was 3.0 (1.0–5.0). Incidence rate of hospitalisation was 1.7 per patient-year in all and 1.9 in atrial fibrillation patients, median duration per hospitalisation was 7.9 (4.8–12.9) and 8.8 (5.7–13.3) days, respectively. Most frequent reasons for hospitalisation were vascular access complication/intervention (11.7%) and infection/fever (11.4%), while bleeding events comprised 6.0% of all hospitalisations. Atrial fibrillation patients had 27% higher risk of hospitalisation than patients without atrial fibrillation (incidence rate ratio [IRR] 1.27, 95% confidence interval [CI] 1.10–1.47). In atrial fibrillation patients, anticoagulation (enoxaparin or phenprocoumon, 41.6% of AF patients) was associated with increased risk of all-cause (IRR 1.38, 95%CI 1.14–1.69) and bleeding-related hospitalisation (IRR 1.96, 95%CI 1.06–3.63). There was no association between anticoagulation and stroke-related hospitalisation. In atrial fibrillation patients on phenprocoumon, increasing time-in-therapeutic range was associated with decreased risk of all-cause (IRR 0.35, 95%CI 0.14–0.87), but not bleeding-related hospitalisation (IRR 0.13, 95%CI 0.01–1.38).ConclusionIn haemodialysis patients, presence of atrial fibrillation and, among those with atrial fibrillation, anticoagulation were associated with higher risk of all-cause hospitalisation, including bleeding-related hospitalisation in the latter. Increasing time-in-therapeutic range in patients on vitamin K antagonist treatment was associated with decreased risk of all-cause, but not bleeding-related hospitalisation.

Pharmacy technician-led general practice support hub: a feasibility study

Abstract Introduction Workforce pressures in general practice have led to Scottish Government initiatives to integrate pharmacy teams into general practice. The focus is completion of prescribing management-related activities releasing general practitioner time for patient-focused workload.1 Activities include medicines reconciliation from immediate discharge letters (IDL), processing outpatient prescription requests (OPL) and special request prescriptions (SR). Pharmacists effectively mobilise GP capacity completing these tasks.2 However, pharmacists may aspire to advanced practice roles including medication review case-load management. Therefore, alternative workload delivery models including centralised pharmacy technician-led general practice support hubs to complete IDL, OPL and SR tasks must be considered. National guidance outlines that pharmacy technicians may complete these tasks autonomously with minimal supervision.3 Unknowns include whether pharmacy technicians can lead this service delivery and the definition of the supervisory support required. Aim To evaluate the feasibility of a pharmacy technician-led hub for completion of SR, IDL and OPL. Methods Feasibility was studied over 4 weeks (12 April – 7 May 2021) during routine service delivery across three medical practices (approx. 23 800 patients) in NHS Greater Glasgow and Clyde. Quantitative real-time self-reported data on the volume of tasks (SR/IDL/OPL), task completion time and volume of pharmacist referrals was collected by pharmacy technicians and pharmacists and analysed in Microsoft Excel®. Qualitative data describing why pharmacy technicians referred tasks to pharmacists was collected and categorized using thematic analysis and Microsoft Excel® by the lead author. Ethical approval was not required for this service evaluation. Results 4485 total tasks were completed: SR 87% (n=3917); IDL 7% (n=323); OPL 6% (n=245). Pharmacy technicians completed most (71%; n=3181) prescribing management-related tasks. A service delivery gap (21%; n=921 of tasks) where workload exceeded technician resource, necessitated pharmacist support. Referral rate for tasks beyond technician competence was 11% (n=383). The locally agreed 48-hour benchmark turnaround to process tasks was achieved for the majority of tasks. Breaches of the target were noted: 53 (1%) SR; 10 (3%) IDL and 5 (2%) OPL. Technicians and pharmacists completed tasks in numerically similar times. 383 tasks were referred to a pharmacist. 134 (35%) tasks could only be completed by a pharmacists due to the need for a prescribing decision or pharmacist-specific knowledge. 226 (59%) could be completed by a technician with additional knowledge or training. Examples include queries requiring interpretation of clinical parameters or blood monitoring or answering medicines information enquiries. 6% (n=23) of referrals were uncategorised due to incomplete data collection. Discussion/Conclusion This study provides new information describing the workload volume achieved by pharmacy technicians and characterising the supervisory role of the pharmacist. Pharmacy technicians convincingly completed most activities. Service delivery gaps need addressed including maintenance of service delivery during periods of authorised absence and professional development time. Pharmacist referral rate can be improved by upskilling pharmacy technicians. The volume of SR tasks drives the workload and could be managed more effectively by converting suitable SR tasks to controlled repeats. A Health Improvement Scotland initiative is developing this work stream. Additional projects must identify training gaps to understand technician development needs and analyse achievement of advanced pharmacist activities where technician-led hub exists.

An audit of discharge medicines counselling on an acute elderly admissions unit

Abstract Introduction Poor discharge communication is a major contributor to medication-related errors during care transfers. The World Health Organisation 2019 Medication Safety report1 acknowledged this and recommended prioritising collaboration with patients/families/carers, communicating medication changes, and interdisciplinary working. The Care Quality Commission 2020 National Patient Inpatient Survey found that only 28% of participants received information regarding side-effects, 55% given explanations on medicines-use, 48% provided written information and 12% no information.2. Health information systems including Medicines a Patient Profile Summary (MaPPs) provide easy-read leaflets which may improve patient awareness and understanding of their medicines.3 This study explored patients’ experience of DMC at one hospital Trust. Aim To measure patient satisfaction and understanding of DMC offered at Mid Yorkshire Hospitals Trust and establish whether the Trust standards were met of all patients with medication changes (new/stopped/changed) receiving verbal DMC and being offered a MaPPs leaflets/charts documenting the changes. Method Ethics approval was not required for this service evaluation. Baseline data was collected from the Trust Medicines Information department to establish which ward had the most discharge enquiries in October 2021. Inpatients from this ward were included if they were elderly, had a previous admission within the last 2 months, usually lived at home and managed their own medications or had help from relatives/friends. Inpatients were excluded if they were care-homes residents, had carers who visited to administer medicines, used a compliance aid or had no medication changes. A 13-item questionnaire was designed for qualitative/quantitative data collection over a 4-week period in December 2021. Questions concerned discharge medicines information provided (written/verbal), patient/relative satisfaction and patient/relative understanding of medicines indicated and changes. Quantitative data underwent descriptive statistical analysis, whilst qualitative data were grouped by similarity and frequency counted. Results A total of 20 elderly patients/relatives were included: 11 were female and 9 were male. Eight respondents (40%) reported not receiving written information. Twelve respondents (60%) reported received a SystmOne discharge letter, of whom 7 received additional written information that included a discharge medication list. This was provided by nurses on all occasions. No respondents reported being offered a MaPPs leaflet/chart, but 17 respondents indicated that they thought that a MaPPs leaflets/chart would have been beneficial. Eleven respondents reported receiving verbal DMC, of whom 4 rated themselves as being “not very satisfied” with it. Key themes were: ‘rushed discharges’, ‘limited patient/relative involvement’. No respondents reported being informed about side-effects. Eleven and 14 respondents respectively reported partially/not fully understanding why medications were indicated or changes made. Discussion/Conclusion Overall, DMC was below the Trust standards. Poor explanation of changes and no information on side-effects was common practice. The findings are limited by the small sample size and limited generalisability to ethnic minorities. Future study plans include involving underrepresented patient groups in a larger sample. Nevertheless, the following recommendations were made: Offer all patients MaPPs leaflets/reminder charts and verbal DMC; Offer all elderly ward nurses pharmacy-led MaPPs training; add monthly reminders during morning handovers to use MaPPs; Document on the electronic prescribing system when MaPPs leaflets are provided.

346 A RETROSPECTIVE REVIEW OF THE PREVALENCE, MANAGEMENT AND SPECIALIST REVIEW OF TIA DIAGNOSIS

Abstract Background Transient Ischaemic Attach (TIA) and suspected TIA are common presentations to emergency departments and stroke services, often heralding a subsequent stroke in up to 25% of patients. The first week after TIA symptom onset carries a significant risk of impending stroke, reported risk at 2 days of between 2.0 and 4.1%, and at 7 days of between 3.9 and 6.5%. As such, a TIA presentation may offer an opportunity to reduce the significant risk of chronic morbidity and mortality. Methods We conducted a retrospective review of all patient records with a diagnosis of TIA on their clinical discharge summary using the HIPE system from June 2020 to June 2021. Results Two-hundred and Sixty-nine patients were recruited into the study. 77 patients without discharge letters or incomplete medical information were excluded. The remaining 192 were analysed. Mean age was 75 (+/-10), 45.8% (n=88) patients were male and average length of stay 3.9 days. 52.6% (n=101) were followed up in designated TIA or Neurology OPD, 42.2% (n=81) were confirmed TIA. 10.4%(n=20) were diagnosed with another pathology. 47.4% (n=91) did not have any OPD follow up care. 100% of OPD confirmed TIA cases (n=81) were on anti-platelet or anticoagulation therapy. 4 out of 9 confirmed TIA cases with high HbA1c levels had no prior history of diabetes. 4.2% (n=8) were actively smoking and not on nicotine replacement therapy. 27.2% (n=22) had a history of previous TIA. Conclusion Accurate TIA recognition and management remains crucial to stroke prevention. Outpatient follow up in TIA and Neurology clinics can improve TIA diagnosis and guide appropriate management. Despite guidelines recommending an early referral to a stroke team, almost half (47%) of those patients diagnosed with TIA during admission did not have OPD follow up. TIA mimics represent a considerable pitfall in TIA diagnosis for NCHDs.

223 READMISSION POST STROKE: RATES AND REASONS FOR READMISSION IN THE 18 MONTHS FOLLOWING HOSPITAL DISCHARGE

Abstract Background The Irish healthcare system faces the same challenges presented to healthcare systems worldwide, ageing populations and the increasing disease burden from chronic conditions. There is a need to respond to and meet these challenges placed on an already pressurized healthcare systems originally set up to respond to acute, episodic care. It would be beneficial to review reasons for unplanned readmissions post stroke to examine whether these readmissions could be predicted, targeted and prevented and whether there are individuals who could be targeted for intervention post hospital discharge, to reduce readmission rates post stroke. Methods Using data from the Hospital In-Patient Enquiry (HIPE) patients were identified who had been discharged with a primary diagnosis of stroke. Data was then examined to identify whether these patients had acute hospital readmissions in the 18-month period following discharge for stroke. Using HIPE and patient discharge letters we identified the reasons for these readmissions and categorized them accordingly. Results A total of 224 live stroke discharges were identified from 2018. 77 patients were readmitted within 18 months of discharge. In total these 77 patients accounted for 139 admissions. Of the 77 patients that were readmitted average Length of Stay (LOS) was 19 days. Of the 77, 12 were due to recurrent stroke while 49 presented with a new complaint that fell into one of the following four categories, pneumonia, falls/fractures, dementia related, medical complications/medication related Conclusion There is a need to identify the unmet needs of stroke patients post hospital discharge so as to reduce the number of readmissions. This would involve screening to identify those suitable to attend a specialist multidisciplinary six-month review clinic where these patients could have onward referral to the appropriate in hospital and community services including intensive dysphagia clinics, therapy-lead spasticity clinic, upper limb rehabilitation programmes, and medical social work support for unmet needs with links to the community.

196 AN AUDIT OF PROTON-PUMP INHIBITOR PRESCRIBING IN PATIENTS ATTENDING A RAPID ACCESS FRAILTY ASSESSMENT UNIT

Abstract Background Proton-Pump Inhibitor (PPI) usage has revolutionised gastroenterology practice with clinical indications for conditions such as Gastro-Oesophageal Reflux Disease (GORD), gastric and duodenal ulceration and Barrett's Oesophagus. However, these drugs are inappropriately prescribed, particularly among patients with an already heavy polypharmacy burden. PPI usage has been linked with electrolyte disturbances, most commonly hypomagnesaemia, resulting in higher rates of osteoporosis. It has also been shown to have adverse effects on renal function, an increased correlation with clostridium difficile and most recently, a deleterious impact on cognitive function. The purpose of this audit was to assess the appropriateness and clinical indication of PPI prescribing among patients attending Rapid Access Frailty Assessment Unit (RAFAU) in 2022. Methods A database of patients attending RAFAU in an Irish regional hospital was accessed. Records from years 2021-2022 were searched and documents citing patients’ medical history and clinical indication for prescribed medications included hospital discharge letters, outpatient clinic letters and GP referral letters. NICE guidelines from the UK NHS were used as comparison for prescribing guidelines. Results 120 patients’ records were assessed. 63 (52.5%) patients were found to be prescribed a PPI among this cohort. Of those taking PPIs, only 15 (23.8%) patients were prescribed a PPI with a documented clinical indication in accordance with NICE Guidelines. Although several patients were taking gastro-erosive drugs including antiplatelets, anticoagulants and steroids, only one patient record mentioned PPIs being prescribed for iatrogenic gastritis. No records mentioned deprescribing or cessation of PPIs. Conclusion Most patients prescribed PPIs were without documented appropriate clinical indication and without clear duration of use. This is of particular importance among a frailty population where de-prescribing medications associated with significant co-morbidities should be prioritised.

The development of new Electronic Health Record Exchange Format Use Cases - an evaluating perspective

Abstract The EU-funded X-eHealth project aims to lay the foundations for a common framework for medical imaging, discharge letters, laboratory results and rare diseases to advance an interoperable Common European Health Data Space for citizens and healthcare providers in accordance with privacy and cybersecurity regulations. To ensure sustainability of the project, it is crucial to assess whether X-eHealth is achieving its planned objectives and delivers tangible results. A key challenge in evaluating project outcomes lies in the partial lack of visibility of direct impacts due to a time lag of effects or attribution problems (i.e., identifying the main cause of a particular impact). In X-eHealth, we address this problem by defining a framework of Key Performance Indicators (KPI) that allows the monitoring of project outcomes. In addition, qualitative interviews with a focus on the following questions are conducted towards the end of the project to complement the evaluation: • Does X-eHealth advance the integration process of eHealth services in Europe? • Will X-eHealth lead to increased use of the new European Electronic Health Record Exchange Format (EEHRxF) specifications? Although final results are not yet available, we expect X-eHealth to have a positive impact at all stakeholder levels by accelerating the implementation of EEHRxF through the harmonisation of health data, thus providing patients, health professionals and institutions with increased quality, safety and efficiency. There is little evidence to analyse the impact of eHealth policy interventions. For this reason, the present evaluation makes a significant contribution to impact research in this area. X-eHealth highlights the importance of international cooperation in creating a common framework for the future development of digital health in the EU. The continuous evaluation, moreover, facilitates a more efficient management of resources through KPI observance and the implementation of project results. Key messages • X-eHealth aims to accelerate the implementation of the European eHealth Record exchange Format (EEHRxF) through the standardisation and harmonisation of health data. • By evaluating and monitoring the project processes, it is possible to ensure the progress of the project and to measure the potential impacts of the outcomes on stakeholders and other target groups.

The Reduction of Left Ventricle Ejection Fraction after Multi-Vessel PCI during Acute Myocardial Infarction as a Predictor of Major Adverse Cardiac Events in Long-Term Follow-Up.

Background: Revascularisation strategy in patients with multi-vessel coronary disease and acute myocardial infarction (AMI) remains challenging. One of the potential treatment options is complete percutaneous revascularisation during index hospitalisation. This strategy could positively influence left ventricle ejection fraction (LVEF). Aim: To investigate the long-term changes in LVEF and clinical outcome among patients with AMI after complete coronary revascularisation (CCR). Methods: Records of 171 patients with a diagnosis of AMI and multi-vessel coronary artery disease (CAD) on index angiography, in whom CCR was performed as a staged procedure during initial hospitalisation, were analysed. Clinical data were collected from in-hospital medical records and discharge letters. Cardiac ultrasound (CU), with particular assessment of LVEF, was performed one day before discharge. Follow-up (FU) CU was collected from the out-patient department at least six months ± one week after discharge. Follow-up data, including major adverse cardiac events (MACE), were collected during follow-up visits by telephone. Depending on the LVEF change during the follow-up period, patients were divided into two groups. Patients with a decrease in the LVEF (D-LVEF group) were compared with patients with no changes (preserved) or improvement regarding LVEF (P/I-LVEF). Results: The median duration of the follow-up was 19 months (14–24 months). The median change in LVEF during observation was –5.0p% (IQR (–7.0)–(-2.75p.%)) in the D-LVEF group and +4.0% (IQR 1.0–5.0p%) in the P/I-LVEF group. Among patients in the P/I-LVEF group, there was a sub-group of patients with no change in LVEF (28 patients), and one demonstrating improvement in LVEF (104 patients). In the subgroup of patients with improved LVEF, the median change in LVEF was 4.5p% (IQR 2–6.25p%). Among patients with decreasing LVEF, there was a significantly higher risk of MACE (15 vs. 2.3%, p = 0.031), especially non-fatal AMI (10 vs. 0%, p = 0.017). We found the following among predictors concerning increased risk of MACE occurrence: urgent PCI (p = 0.004), hospitalisations regardless of cause (p = 0.028), EF worsening (p = 0.025), fasting glucose serum concentration (p = 0.024) and fasting triglyceride serum concentration (p = 0.027). Conclusions: Complete revascularisation (CR) at baseline (one stage) in patients with AMI and multi-vessel disease is associated with LVEF improvement and MACE rate reduction. Patients with worse LVEF have poor clinical outcome and a higher rate of MACE.

Patients parameters and results of the tilt table test depending on referrals

Abstract Introduction The tilt table examination (TTT) is used to investigate patients with syncope for 50 years, and was downgraded by the 2018 Guidelines of the European Society of Cardiology for syncope-evaluation from class I to II a/b. Aim Aim of the study was to assess changes in the referrals for TTT from 2014 to 2018. In addition, it was examined if there were differences in the history, clinical findings, and results of the TTT among patients depending on the referral for TTT. Patients and methods Included in the retrospective cohort study were 205 patients, 49% females, mean age 52 (15–82) years, in whom TTT was carried out between 2014 and 2018 in a cardiology department. Information from the discharge letters and electronic hospital information system was collected. Results Referrals for TTT were suspected orthostatic hypotension (OH) (n=53), suspected reflex syncope (n=98), and unexplained syncope (n=54). By TTT the diagnosis of OH was established in 32%, reflex syncope in 27%, and postural orthostatic tachycardia syndrome in 16%. There was an increase of positive TTT findings from 2016 to 2018 (54 to 79%, p=0.039). The referrals for unexplained syncope decreased from 2014 to 2018 (33 vs. 14%, p=0.039). Compared to patients with suspected reflex syncope, patients with unexplained syncope suffered more from coronary artery disease (CHD) (19 vs. 5%, p=0.011) and arrhythmias (24 vs. 10%, p=0.032), were more often taking beta-blockers (26 vs. 7%, p=0.002) and more often had ST-segment abnormalities (11 vs. 1%, p=0.008). Compared to patients with suspected OH, patients with unexplained syncope suffered more from palpitations (11 vs. 8%, p=0.0024). Compared to patients with suspected reflex syncope, patients with suspected OH had more comorbidities such as CHD (17 vs. 5%, p=0.036), hypertension (45 vs. 18%, p=0.01), diabetes mellitus (25 vs. 3%, p=0.0) and synucleinopathies (6 vs. 0%, p=0.042) and took more antidiabetic (23 vs. 4%, p=0.001), antithrombotic (42 vs. 12%, p=0.0), diuretic (15 vs. 2%, p=0.004), beta blocking (23 vs. 7%, p=0.009), anticonvulsant (6 vs. 0%, p=0.042), antiparkinsonian (6 vs. 0%, p=0.042), antidepressant agents (26 vs. 11%, p=0.022) and statins (26 vs. 8%, p=0.004). Compared to patients with suspected OH, patients with suspected reflex syncope suffered more from prodromes like flushing (17 vs. 2%, p=0.001) and nausea (33 vs. 8%, p=0.004). Conclusions If patients are referred for appropriate reasons, the TTT has a high diagnostic value. The results confirm other studies indicating that unexplained syncope may suggest a cardiac origin. Funding Acknowledgement Type of funding sources: None.

Clinical and surgical factors for successful stoma reversal in patients with Crohn's disease-results of a retrospective cohort study.

Despite the wide range of medical and interventional therapy options available, some patients with Crohn's disease (CD) need an ileostomy or colostomy. The aim of this study was to identify clinical, surgical and drug-related predictors of successful stoma reversal in CD patients. A retrospective medical record analysis of surgical department logs, hospital discharge letters and patient reports from outpatient departments was performed for all CD patients who underwent a first ostomy surgery. Our study analysed a total of 149 patients (76 women, 73 men, median age at first stoma of 34years after a median CD duration of 9years), with a median follow-up of 78.4 (IQR 88.6) months after first ostomy surgery. Of these patients, 73 (49%) underwent stoma reversal after a median of 11.7months (IQR 15.7months) of whom 17 (23.3%) needed a second stoma. In multivariant analysis, Montreal A1 classification (HR 2.07; 95% confidence interval 1.23-3.47; p = 0.006), a primary laparotomy (HR 2.30; 95% confidence interval 1.20-4.41; p = 0.012) and the absence of perianal/rectal CD activity (HR 3.00; 95% confidence interval 1.86-4.86; p < 0.001) emerged as independent predictors of a shorter time to stoma reversal. Introduction or switch of biological therapy after first stoma was not associated with successful reversal of the stoma (OR 4.6 95% confidence interval 1.45-14.66; p = 0.01). Laboratory parameters had no influence. Clinical and surgical features-rather than medication or laboratory findings-were found to be predictors of successful stoma reversal in CD patients. Future studies focusing on the definition of a Standard Operation Procedure for emergency and elective CD surgery are warranted.

Development and validation of a prediction rule for patients suspected of acute coronary syndrome in primary care: a cross-sectional study

ObjectiveTo develop and validate a symptom-based prediction rule for early recognition of acute coronary syndrome (ACS) in patients with acute chest discomfort who call out-of-hours services for primary care (OHS-PC).DesignCross-sectional...

A social ecological approach to promote learning health disparities in the clinical years: impact of a home-visiting educational program for medical students

BackgroundThere is consensus that medical schools have a duty to educate students about social determinants of health (SDOH) and equip them with skills required to ameliorate health disparities. Although the National Academy of Medicine (NAM) urged the development of experiential long term programs, teaching is usually conducted in the pre-clinical years or as voluntary courses. ETGAR a required health disparities course, based on the social ecological model, was initiated to answer the NAM call. This study aimed to ascertain the course impact on students learning of SDOH and health disparities.MethodsStudents during their first clinical year cared for four patients in their transition from hospital back home, one patient in each internal medicine, surgery, pediatrics and obstetrics/gynecology rotation. The students home-visited their patients after meeting them in hospital and preparing a plain language discharge letter. Training session prior to the course, a tutorial in each rotation, and structured feedback gave the educational envelope. Mixed methodology was employed to evaluate the course impact. Quantitative data collected by students during the home-visit: patients’ characteristics and quality and safety of the transition back home using the Medication Discrepancy Tool and Care Transition Measure questionnaire. Stakeholders’ views were collected via interviews and focus groups with students representing all affiliated hospitals, and interviews with heads of departments most involved in the course.ResultsThree hundred six students in three academic years, between October 2016–July 2019, completed home visits for 485 disadvantaged patients with improvement in patients’ knowledge of their treatment (3.2 (0.96) vs 3.8 (0.57), Z = -7.12, p < .0001) and identification of medication discrepancies in 42% of visits. Four themes emerged from the qualitative analysis: contribution to learning, experience-based learning, professional identity formation, and course implementation.ConclusionsETGAR was perceived to complement hospital-based learning, making students witness the interaction between patients’ circumstances and health and exposing them to four patients’ environment levels. It provided a didactic framework for promoting awareness to SDOH and tools and behaviors required to ameliorate their impact on health and health disparities.The course combined communication and community learning into traditionally bio-medical clinical years and serves as a model for how social-ecology approaches can be integrated into the curriculum.