Gold Standards Framework Research Articles

The Effectiveness of Palliative Care Interventions in Long-Term Care Facilities: A Systematic Review.

The increasing elderly population is driving higher utilization rates of long-term care facilities, where residents often have multiple chronic diseases, making them potential candidates for palliative care. Timely palliative care interventions can improve their quality of life and medical autonomy. This study systematically reviews the effectiveness of palliative care programs in long-term care facilities. Databases such as PubMed, EMBASE, Cochrane Library, and Airiti Library were searched up to 31 December 2023, using PICO criteria and the following keywords: 'care home', 'nursing home', 'residential aged care facility', and 'long-term care facility' for patients; and 'Gold Standard Framework in Care Homes', 'integrated care pathway', 'care home project', and 'palliative care program' for interventions. Seven articles were included. The results indicate that the Program of All-Inclusive Care for the Elderly (PACE) intervention did not significantly influence overall quality of life but did improve the quality of death. There were no statistical differences in comfort or quality of death between the dementia and non-dementia groups. However, PACE significantly reduced healthcare costs. The implementation of the Liverpool Care Pathway (LCP) notably enhanced the control of terminal symptoms, while the Gold Standard Framework in Care Homes (GSFCH) effectively improved end-of-life care rates, do-not-resuscitate (DNR) signing rates, advance care planning (ACP) completion rates, and reduced inappropriate readmission rates. While palliative care interventions are shown to improve the quality of end-of-life care, their practical application should be adapted to fit the implementation conditions and capabilities of domestic long-term care facilities.

A period prevalence study of palliative care need in adult outpatients

High levels of unmet palliative care need are reported globally. There is limited research that investigates unmet palliative care need in outpatient contexts. Early access to palliative care services is associated with better symptom management and reduced healthcare costs. This semi-replication study aimed to gain an understanding of palliative care need and service utilisation in adult outpatients attending a hospital outpatient day treatment unit. An observational period prevalence study was conducted using the Gold Standard Framework Proactive Indication Guidance to assess for palliative care need. Data were collected directly from the electronic medical records of patients who attended an outpatient day treatment unit, at a private-not-for-profit hospital over five days in January 2022. The indicators for the 12 conditions outlined in the Gold Standards Framework Proactive Indication Guidance were used to assess for palliative care need. Based on the review 41% (n = 115) of adult outpatients may have benefitted from palliative care. Of these, 13% (n = 15) were currently receiving palliative care, and most patients (87%, n = 100) were not receiving palliative care. There was evidence of high levels of unmet palliative care need, with most patients who could benefit from not receiving palliative care.

Paramedic utility in screening patients who present to Emergency Medical Services and who may benefit from an Advance Care Plan: A mixed methods study with explanatory sequential design

We used a two-phased mixed methods study with an explanatory sequential design to understand how frequently paramedics attend patients who, on paramedic assessment with the Gold Standards Framework Proactive Identification Guidance, are end-of-life and have advance care planning. We subsequently explored paramedic views on paramedic screening of patients to assess if they are end-of-life and onward referral to their General Practitioner for advance care planning. Paramedics screened and recorded 14.9% of patients as end-of-life and 44.3% of these patients were assessed to have no advance care plan in place. When paramedics screened patients and they did have an advance care plan in place, 36.8% had only a Do Not Attempt Cardiopulmonary Resuscitation. Paramedics found using the Gold Standards Framework Proactive Identification Guidance to screen patients for end-of-life status useful and straightforward and considered themselves well-placed to complete this task. Future research is required to address the practicalities of implementing a paramedic screening and referral tool for end-of-life care that results in the intended outcome of supporting effective advance care planning.

1953 Improving access to community palliative care by raising awareness of services, indications for referral and referral pathways

Abstract Introduction 40% of 1056 patients discharged from our acute geriatrics ward met Gold Standards Framework (GSF) Prognostic Indicator Guidance for Recognition of Patients approaching End of Life (EOL). 92% were not referred to Community Palliative Care (CPC) services, meaning patients’ needs were not fully met and other services over-stretched. This project aimed to achieve a 10% reduction in missed referrals. Methods Highlighting the missed referral rate enabled engagement of key stakeholders including ward and palliative care multidisciplinary teams. This 12-month project comprised four PDSA Cycles: 1. Raising awareness of GSF and CPC through ward-based teaching; 2. Development of posters outlining referral criteria and pathways; 3. Hospital-wide survey of doctors’ understanding of treating patients approaching EOL, with real-time feedback on GSF and CPC; 4. Formal departmental and year-group teaching sessions. The outcome measure was the percentage of patients meeting GSF criteria who were not referred to CPC, as determined by retrospective analysis of discharge letters. Readmission rate was calculated as a marker of quality of life (QoL) and to assess the impact of missed referrals on the Trust. Results Interventions led to a sustained reduction in missed referrals (72% from 92%). Certain diagnoses are more readily referred, metastatic malignancy for example, 9x more frequently than advanced Parkinson’s. Patients meeting criteria averaged 3 admissions in the preceding year (compared to 1.7). Of those meeting criteria and still alive, patients not referred averaged 1 re-admission within 6 months compared to 0.3 when referred. Conclusions Missed CPC referrals impact patient QoL and increase the burden on acute inpatient services. Significant benefits could be seen if these findings are extended to other inpatient wards. There is also a need for education about the palliative stage of non-malignant diseases such as Dementia and Parkinson’s. Future steps include technology-based active screening of inpatients to facilitate referrals.

Process evaluations for the scale-up of complex interventions – A scoping review

Background: Process evaluation (PE) is an essential part of testing and adapting complex health interventions (CHIs) and involves evaluating what is implemented (and how), mechanisms of change, and how context affects implementation and health outcomes. To address complex health needs, the focus is on developing new CHIs, rather than on adapting and scaling up existing interventions to promote stronger integration, increased population coverage, or comprehensiveness. Therefore, more attention is needed to process evaluations conducted during the scale-up process as they may have distinctive features, stakeholders, or objectives. We aim to describe the current practice of process evaluations conducted during the scale-up of CHIs.
 Who is it for? The results of this review are relevant to all stakeholders involved in the scale-up of CHI.
 Who did you involve and engage with? All authors of this review have been involved in the scale-up of integrated care across multiple contexts.
 What did you do? Eight primary data sources (PubMed, Embase, CENTRAL, Web of Science, CINAHL, Global Health, Scielo and African Index Medicus) and grey literature were searched. Studies were screened following gold standard review procedures. Study demographics, scale-up dimensions (i.e., integration, coverage, comprehensiveness), features of the complex intervention and PE were charted. Process evaluation was further assessed in terms of stakeholders involved and proposed objectives of the PE. For this review, the United Kingdom Medical Research Council’s (MRC) definition of PE was adjusted in terms of “scale-up” instead of “delivery and functioning.”
 What results did you get? We identified 10303 unique records of which 34 were included after abstract (n=223) and full-text (n=91) screening. Twenty of the 34 studies were conducted in one or more low-middle income countries (LMICs). Most CHIs studied looked at scale-up of interventions for patient empowerment through digital health, strengthening primary care, or person-centered care models. In the absence of a guiding framework for PEs in the context of scale-up, a variety of other frameworks were often used including the RE-AIM framework (n=5), Consolidated Framework for Implementation Research (n=3), or MRC framework for the PE of CHIs (n=1). Some of these frameworks were subsequently adapted to facilitate unexpected pathways to impact or interactions with contextual factors to emerge as well. Interestingly, in 12 out of 34 studies, beneficiaries (e.g., patients) were not stakeholders in the PE.
 What is the learning for the international audience? Process evaluations specific to the process of scaling up is advertently different from implementing a CHI. In the absence of a gold standard framework to guide PE during scale-up, the development of such guidance could be considered.
 What are the next steps? We plan to seek further engagement, including with those funded under the “Global Alliance of Chronic Disease” scale-up program, to determine the value and content of a process evaluation framework for scale-up.

The Global ALPL gene variant classification project: Dedicated to deciphering variants

BackgroundHypophosphatasia (HPP) is an inherited multisystem disorder predominantly affecting the mineralization of bones and teeth. HPP is caused by pathogenic variants in ALPL, which encodes tissue non-specific alkaline phosphatase (TNSALP). Variants of uncertain significance (VUS) cause diagnostic delay and uncertainty amongst patients and health care providers. ResultsThe ALPL gene variant database (https://alplmutationdatabase.jku.at/) is an open-access archive for interpretation of the clinical significance of variants reported in ALPL. The database contains coding and non-coding variants, including single nucleotide variants, insertions/deletions and structural variants affecting coding or non-coding sequences of ALPL. Each variant in the database is displayed with details explaining the corresponding pathogenicity, and all reported genotypes and phenotypes, including references. In 2021, the ALPL gene variant classification project was established to reclassify VUS and continuously assess and update genetic, phenotypic, and functional variant information in the database. For this purpose, the database provides a unique submission system for clinicians, geneticists, genetic counselors, and researchers to submit VUS within ALPL for classification. An international, multidisciplinary consortium of HPP experts has been established to reclassify the submitted VUS using a multi-step process adhering to the stringent ACMG/AMP variant classification guidelines. These steps include a clinical phenotype assessment, deep literature research including artificial intelligence technology, molecular genetic assessment, and in-vitro functional testing of variants in a co-transfection model to measure ALP residual activity. ConclusionThis classification project and the ALPL gene variant database will serve the global medical community, widen the genotypic and phenotypic HPP spectrum by reporting and characterizing new ALPL variants based on ACMG/AMP criteria and thus facilitate improved genetic counseling and medical decision-making for affected patients and families. The project may also serve as a gold standard framework for multidisciplinary collaboration for variant interpretation in other rare diseases.

1215 IMPROVING THE QUALITY OF ANTICIPATORY CARE PLANNING FOR PATIENTS WITH RECURRENT ASPIRATION PNEUMONIA

Abstract Introduction Recurrent episodes of aspiration pneumonia (RAP) are a significant problem in frail patients leading to high re-hospitalization and mortality. Anticipatory care planning (ACP) enables improved quality of life and end of life care. We reviewed the assessment, ACP discussions and communication with Primary Care in these patients. Methods We used a PDSA methodology, reviewing 116 patients with RAP referred to Speech and Language Therapy (SLT) in Elderly Medicine wards over six months, including the winter. Educational interventions were implemented. An illustrative case and pre-intervention results were presented at an online hospital-wide seminar and subsequently at an online departmental medical staff teaching session. Post-intervention analysis of 10 patients with RAP admitted over two summer months was conducted. The second round of interventions included departmental induction teaching for newly rotated doctors and creating an electronic ACP document (RAP ACP) for inclusion within the medical record. Results Baseline data was collected from 116 patients (mean age 85, 47% female). After the educational interventions, data was collected from 10 patients (mean age 88, 70% female). Data is being collected from winter months after the second intervention. This will be available before the conference. Baseline data demonstrated the need for improvements in documentation of Mental Capacity Assessment (MCA) specific to feeding (21.5%), ACP completion (26.7%) and flagging patients suitable for the Gold Standards Framework (GSF) on discharge (15%). Following educational interventions, there was a substantial improvement in MCA documentation (80%). Furthermore, there was a marked improvement in the completion of ACP discussions (70%). Communication of patients eligible for GSF was similar (14.2%) post-intervention. Conclusions Educational interventions substantially improved the quality of individualised care provided to patients with RAP. Mortality was high in both groups, yet documentation of eligibility for GSF was low, prompting further interventions targeting discharge communication.

Evaluating the Contribution of Complex International Research-for-Development Programmes to the Sustainable Development Goals

While evaluation of research-to-policy projects is a fundamental aspect of measuring the impact of new knowledge, limited studies have examined evaluation methods in such projects, as well as how the evaluation can generate learning to facilitate the progress towards the Sustainable Development Goals (SDGs). This study conducted a systematic literature review and found that the most commonly used methods for SDG contribution evaluation were Analytical Hierarchy Process (40.4%), Fuzzy TOPSIS (13.2%) and ELECTRE and SPADE Methodology (3.5% each). Ranking analysis was undertaken to determine priorities among the six “Big Wins” as defined for the UKRI-GCRF Trade Hub Project, as a case, where the ranking was exercised by the project partners across the globe. Results revealed that “nature and social factors” was better considered in international trade agreements as the priority (36.4%) among others. Moreover, among the four “mechanisms” of the project, “knowledge, networks, and connectivity” was ranked as the top priority (56.9%), followed by “capacity building” (28.5%), “metrics, tools and models” (7.2%), and “improving the knowledge base” (4.6%). Mapping and evaluation revealed that the Big Wins of the Trade Hub contributed to ten out of the 17 SDGs. The most fulfilled goals were SDG 12 (Sustainable Consumption and Production), SDG 15 (Life on Land), and SDG 2 (Zero Hunger) in descending order. Furthermore, interaction analysis of the core SDGs revealed both synergy and tradeoff between different outputs. The research articles reviewed for this paper showed no gold standard framework for assessing international development projects against the SDGs. Further research should develop a tool to capture holistic and synergistic contributions of the target outcomes of projects to sustainable development.

Documentation of Just in Case (JiC) medication for end of life patients in care homes looked after by a general practice.

This project was undertaken to improve the documentation of Just in Case (JiC) medication in a general practice. The outcome of a Strengths, Weaknesses, Opportunities, Threats (SWOT) analysis highlighted this as an area where awareness within the practice could be improved. A Plan-Do-Study-Act (PDSA) approach was taken to the project and involved collaborative working and data collection from the general practice and relevant care homes. JiC medications are used to promptly manage symptoms experienced at the end of a patient's life and are part of the Gold Standard Framework (2006). Of the patients registered at the practice with JiC medication, 37.5% were incorrectly documented. This included errors/ inaccuracy with the clinical coding, orthe medication. Three patients on practice generated searches had no JiC medication in the care homes, and 4 patients had JiC boxes in the care home that was not identified by the search. This evaluation has identified documentation errors and discrepancies between practice and community records of JiC medication. A newly generated practice specific flowchart was created, with an aim of reducing the discrepancies. A guide of how to carry out a QI project like this was created for the RCGP and can be found on their website. A seminar at Bristol, North Somerset, and South Gloucestershire (BNSSG) CCG to present this project took place in 2021.

1012 ASSESSING THE CLINICAL EFFECTIVENESS OF EMERGENCY HEALTH CARE PLANS (EHCPS); A RETROSPECTIVE REVIEW

Abstract Introduction Almost 30% of hospital patients are in their last year of life; mortality is five times higher one year post-hospital admission for patients aged 85+ (Clark D, Armstrong M. Palliative Medicine, 2014, 28, 474–479). Studies have shown 40–50% of those who die in hospital could have died in the community (End of Life Care, National Audit Office, 2008). As a geriatric department, we wanted to adopt existing good practice to ensure we were recognising individuals in their last 12 months of life and enabling them to die where they chose. Method Using the Gold Standards Framework (Clifford C, Thomas K, Armstrong-Wilson J. End of Life, 2016, 6) in 2019 DrZin introduced a standardised document for EHCPs. We reviewed 123 EHCPs implemented March 2019—August 2021, focusing on the number of attendances to A&E in the year prior to implementation, the number of avoidable admissions to hospital following completion of an EHCP, and place of death. Results Of 123 patients, the mean number of A&E attendances in the year before EHCP implementation was 2.52 per patient; post implementation it was 0.18. There were 22 A&E attendances after implementation (17.8%); all resulted in an admission. Of those, 12 (54.5%) were deemed avoidable. There were 100 deaths (81.3%) within 12 months of implementation; 5% died in hospital. Conclusion 95% of patients with an EHCP died in their preferred setting. Having an EHCP reduced patients’ attendance to A&E. However, work is required to reduce avoidable attendances, through education for GPs and community carers. Although every EHCP was sent to the patient’s GP and residence, several attendances contained no reference to the patient having an EHCP. Therefore, the next step of our project will be creating an alert for patients with an EHCP on their electronic record and re-reviewing hospital admissions rates.

993 IMPROVING ADVANCE CARE PLANNING ON A GERIATRICS WARD: A QUALITY IMPROVEMENT PROJECT

Abstract Introduction Despite ongoing improvement work in our hospital regarding Advance Care Planning (ACP) in the community and specialist palliative care settings, our team was concerned that ACP was underutilized for inpatients. We aimed to increase the number of ACPs (specifically focusing on re-admission avoidance) made on our geriatrics ward, and to communicate these effectively with community colleagues. Method We retrospectively reviewed 26 deaths on our ward during a three-month period, and found significant missed opportunities to discuss ACP, e.g. 54% of patients had more than one admission in the six months prior to death. We developed a novel co-morbidity score to help support our decision-making, and used aspects of the Gold Standards Framework’s Proactive Identification Guidance. Our working group, led by a consultant geriatrician, focused on increasing the team’s engagement with ACP, including use of an ‘ACP Champion’, and we worked to align our documentation with that used elsewhere in the Trust. We used a paper form, resembling a DNACPR, to prompt community teams to re-consider whether admission was necessary. We made ACPs for six patients during this four-month pilot phase, and followed them up over the next five months. Results Following our interventions, follow-up of our patients showed 83% had ACP described in their discharge letter; 33% had ACP mentioned on their Summary Care Record (SCR); 0% of patients who had died re-presented to hospital prior to death. Conclusion Our project showed that diligent attention to making ACPs for suitable patients was successful in preventing re-admission. Despite this, communication about ACPs in the discharge letters and transfer of this information to the SCR was suboptimal. This demonstrates that even with a focused team, mistakes can happen. I’m now working on a subsequent project focusing on improving understanding of ACP amongst junior doctors.

The Gold Standards Framework Hospital programme: implementation and progress.

The implementation and impact of the Gold Standards Framework Hospitals (GSFH) service development programme is described. A third of hospital inpatients may be in their last year of life when admitted to hospital. Many will be repeat and unplanned admissions. National policy guidance seeks to change this pattern through implementing patient choice in end-of-life care (EOLC) planning. GSFH training and resources help general hospital staff teams develop skills as they identify patients nearing the end of life, rapidly assess their needs and offer advance care planning (ACP). Audit data shows teams that have undergone GSFH training demonstrate earlier identification of patients needing EOLC and offer ACP targeting their individual care needs. The model has been taken up by over 350 hospital wards, with a large number seeking accreditation to demonstrate sustainability of good practice in EOLC management.

Integrating Climate Change in the Curriculum: Using Instructional Design Methods to Create an Educational Innovation for Nurse Practitioners in a Doctor of Nursing Practice Program

An applied epidemiology course for doctor of nursing practice students was revised to include a module on the impact of climate change on population health. The Analyze, Design, Develop, Implement, and Evaluate (ADDIE) model of instructional design is a gold standard framework for creating course content and guided the module development. A nurse content expert discussed the environmental impacts of climate change on health using literature, actual clinical scenarios, and the application of epidemiologic data. Topics included safeguarding workers and vulnerable populations within the context of the coronavirus disease 2019 pandemic. Students posted reflections on their understanding of module content in response to structured prompts electronically in the learning management system for review by the faculty. Faculty evaluation of responses identified the need to further develop and integrate environmental epidemiology and climate change content more fully within the doctor of nursing practice curriculum.

A point prevalence study of palliative care need and referral rates in adult inpatients.

To gain an understanding of palliative care need and service utilisation in adult inpatients. The objectives were to 1) Determine the size and characteristics of the population of adult inpatients who were appropriate for palliative care referral, 2) Establish what percentage of patients, who were appropriate for a palliative care referral, had been referred to and/or were receiving palliative care. Internationally there is evidence of high levels of unmet palliative care need. Early access to palliative care is associated with improved outcomes including improved quality of life and reduced healthcare costs. An observational point prevalence study was reported using the STROBE guidelines. Data were collected directly from inpatient medical records at a 578-bed tertiary private-not-for-profit hospital by three Registered Nurses on 3 June 2021. Palliative care need was assessed using the prognostic criteria for the 12 conditions outlined in the Gold Standards Framework. A total of 270 inpatients met study inclusion criteria. At a hospital population level, 29% (n=78) of adult inpatients could have benefitted from palliative care. Of the 78 patients assessed as meeting criteria for palliative care, 29% (n=23) were currently receiving palliative care with a majority of patients 71% (n=55) not receiving palliative care. This study prospectively collected data and included all 12 conditions outlined in the Gold Standards Framework and found a high level of palliative care need. There was evidence of a high level of unmet palliative care need across conditions and treating specialities. Estimates of palliative care need can be used to improve access to palliative care and assess operational requirements, including the staffing levels required to meet the level of palliative care need for adult inpatients.

The PID Principles of Care: Where Are We Now? A Global Status Report Based on the PID Life Index.

A global gold standard framework for primary immunodeficiency (PID) care, structured around six principles, was published in 2014. To measure the implementation status of these principles IPOPI developed the PID Life Index in 2020, an interactive tool aggregating national PID data. This development was combined with a revision of the principles to consider advances in the field of health and science as well as political developments since 2014. The revision resulted in the following six principles: PID diagnosis, treatments, universal health coverage, specialised centres, national patient organisations and registries for PIDs. A questionnaire corresponding to these principles was sent out to IPOPI’s national member organisations and to countries in which IPOPI had medical contacts, and data was gathered from 60 countries. The data demonstrates that, regardless of global scientific progress on PIDs with a growing number of diagnostic tools and better treatment options becoming available, the accessibility and affordability of these remains uneven throughout the world. It is not only visible between regions, but also between countries within the same region. One of the most urgent needs is medical education. In countries without immunologists, patients with PID suffer the risk of remaining undiagnosed or misdiagnosed, resulting in health implications or even death. Many countries also lack the infrastructure needed to carry out more advanced diagnostic tests and perform treatments such as hematopoietic stem cell transplantation or gene therapy. The incapacity to secure appropriate diagnosis and treatments affects the PID environment negatively in these countries. Availability and affordability also remain key issues, as diagnosis and treatments require coverage/reimbursement to ensure that patients with PID can access them in practice, not only in theory. This is still not the case in many countries of the world according to the PID Life Index. Although some countries do perform better than others, to date no country has fully implemented the PID principles of care, confirming the long way ahead to ensure an optimal environment for patients with PID in every country.

Identifying older adults with frailty approaching end-of-life: A systematic review

Background: People with frailty may have specific needs for end-of-life care, but there is no consensus on how to identify these people in a timely way, or whether they will benefit from intervention. Aim: To synthesise evidence on identification of older people with frailty approaching end-of-life, and whether associated intervention improves outcomes. Design: Systematic review (PROSPERO: CRD42020462624). Data sources: Six databases were searched, with no date restrictions, for articles reporting prognostic or intervention studies. Key inclusion criteria were adults aged 65 and over, identified as frail via an established measure. End-of-life was defined as the final 12 months. Key exclusion criteria were proxy definitions of frailty, or studies involving people with cancer, even if also frail. Results: Three articles met the inclusion criteria. Strongest evidence came from one study in English primary care, which showed distinct trajectories in electronic Frailty Index scores in the last 12 months of life, associated with increased risk of death. We found no studies evaluating established clinical tools (e.g. Gold Standards Framework) with existing frail populations. We found no intervention studies; the literature on advance care planning with people with frailty has relied on proxy definitions of frailty. Conclusion: Clear implications for policy and practice are hindered by the lack of studies using an established approach to assessing frailty. Future end-of-life research needs to use explicit approaches to the measurement and reporting of frailty, and address the evidence gap on interventions. A focus on models of care that incorporate a palliative approach is essential.

Uptake of Clinical Prognostic Tools in COPD Exacerbations Requiring Hospitalisation

Clinical prognostic tools are used to objectively predict outcomes in many fields of medicine. Whilst over 400 have been developed for use in chronic obstructive pulmonary disease (COPD), only a minority have undergone full external validation and just one, the DECAF score, has undergone an implementation study supporting use in clinical practice. Little is known about how such tools are used in the UK. We distributed surveys at two time points, in 2017 and 2019, to hospitals included in the Royal College of Physicians of London national COPD secondary care audit program. The survey assessed the use of prognostic tools in routine care of hospitalized COPD patients. Hospital response rates were 71/196 in 2017 and 72/196 in 2019. The use of the DECAF and PEARL scores more than doubled in decisions about unsupported discharge (7%–15.3%), admission avoidance (8.1%–17%) and readmission avoidance (4.8%–13.1%); it more than tripled (8.8%–27.8%) in decisions around hospital-at-home or early supported discharge schemes. In other areas, routine use of clinical prognostic tools was uncommon. In palliative care decisions, the use of the Gold Standards Framework Prognostic Indicator Guidance fell (5.6%–1.4%). In 2017, 43.7% of hospitals used at least one clinical prognostic tool in routine COPD care, increasing to 52.1% in 2019. Such tools can help challenge prognostic pessimism and improve care. To integrate these further into routine clinical care, future research should explore current barriers to their use and focus on implementation studies. Supplemental data for this article is available online at https://dx.doi.org/10.1080/15412555.2021.1959540

MO1039HEALTH PROFESSIONAL PERSPECTIVES OF FRAILTY STATUS EVALUATION DURING PRE-TRANSPLANT ASSESSMENT

Abstract Background and Aims The concept of frailty has garnered increased attention within nephrology in recent years, and there is increased debate on how frailty assessment could be utilized to inform shared decision-making around renal transplantation. A gold standard framework for frailty status workup in pre-transplant assessment remains unestablished. There are significant variations from the methods conducted by clinicians to determine frailty status during pre-transplant assessment. Our study aims to explore the perspectives of nephrology health professionals on frailty assessment in the pre-transplant clinic. Method A 5-item online survey was designed and sent through electronic mail to nephrology consultants, specialist registrars and specialist renal transplant nurses at a tertiary hospital in North West UK. Prior to survey distribution, the final edition was piloted by the authors. Study participants were given 3 weeks during Nov and Dec 2020 to respond. The survey was closed on 16 December 2020. In question 1, respondents are requested to comment on their current practices of frailty assessment in the pre-transplant clinic. Question 2 asked respondents to provide opinion whether frailty screening assessment tools - the Clinical Frailty Scale (CFS) and Fatigue, Resistance, Ambulation, Illnesses and Loss of Weight (FRAIL) questionnaire are useful to help with decisions on patient suitability to progress with pre-transplant assessment. In question 3, respondents are asked to use the CFS and/or FRAIL questionnaire to provide score(s) if applicable, in which they feel a patient would be contraindicated to progress further in pre-transplant assessment. Question 4 asked respondents to share their opinion on whether frailty assessment should be formalized in pre-transplant clinic. Question 5 requested respondents to comment how pre-transplant frailty assessment could be further developed. Survey results were imported into a MS Excel Spreadsheet for analysis. Simple descriptive statistics were used for categorical data. Free text responses were grouped into themes and analyzed using simple qualitative techniques. Results 31 staff members (16 consultants, 10 specialty registrars and 5 specialist renal transplant nurses) were invited to participate in the survey. 26 responses were received by 16 December 2020. 96% (25/26) of respondents commented that medical history gathered on a patient’s ability to perform activities of daily living is the main source used to obtain a general impression and estimate frailty status in the pre-transplant clinic. For 81% (21/26) of respondents, observation of mobility in clinic is also useful to help them determine a patient’s frailty status. While 85% (22/26) of respondents felt the FRAIL questionnaire was not suitable for pre-transplant assessment, 96% (25/26) of respondents agreed that the CFS is an appropriate and applicable frailty screening tool in this context. 92% (24/26) of respondents concur that a CFS score of 6 or higher suggests contraindication for renal transplantation. All 26 respondents agreed that frailty status evaluation should be a formalized process to determine suitability for transplant waitlisting. Popular suggestions to develop frailty assessment in pre-transplant clinic include setting up a frailty multidisciplinary team and frailty scoring system specific for pre-transplant assessment. Conclusion Our survey results suggest nephrology health professionals continue to rely heavily on medical history to evaluate frailty status. Incorporating frailty screening assessment tools such as the CFS prior to comprehensive geriatric assessment may be an option to assist shared decision-making of whether to proceed with next steps of the pre-transplant assessment. Future research initiatives could explore ways towards a systematic approach to frailty status workup and improve cost-effectiveness of the pre-transplant evaluation process.

Integrating Palliative Care Assessment Tools to Enhance Understanding of Illness Trajectory in Post-Acute Care and Long-Term Care

To determine whether education and integration of the Gold Standard Framework Proactive Identification Guidance (GSF-PIG) and the Palliative Performance Scale (PPS) into care rounds, in post-acute care settings, can facilitate communication between the interprofessional care team to enhance understanding of illness trajectories, identifying those who would benefit from a palliative approach to care. Interprofessional care teams received training on the GSF-PIG and PPS which were integrated into weekly care rounds and completed a post-evaluation survey. A chart review was conducted for the 40 patients and residents reviewed with the GSF-PIG and PPS. Data analysis included descriptive statistics and comparisons of characteristics between patients and residents who were grouped as positive or negative on the GFS-PIG surprise question using chi square analyzes and t-tests. The GSF-PIG and PPS were found to enhance communication within care teams and enhance understanding of patient and resident's illness burden. The chart review revealed that patients and residents whom the team would not be surprised if they died within 1 year were older (p = .002), had a lower PPS score (p = .002) and had more indicators of decline (p < .001) compared to patients and residents the team would be surprised if they died within the year. Training interprofessional care teams on the utilization and integration of the GSF-PIG and PPS during weekly care rounds helped increase the understanding of patient and resident illness burden and illness trajectory to identify those who may benefit from a palliative approach to care.

73 Using the Gold Standards Framework to Identify Opportunities for Advance Care Planning

Abstract Introduction Departmental discharge data (January 2017–January 2018) suggested a high number of “Day 1 Deaths” i.e. an individual who was readmitted 24 hours after discharge, and subsequently died during their readmission. We wondered if this was due to a lack of Advance Care Planning (ACP). Methods We undertook a retrospective case note audit of 50 cases from the “readmissions who died” (total 176/7421) subgroup, to understand whether or not they were predictably within the last days, weeks or months of life and whether there was ACP in place. We reviewed all Day 1 Deaths (16/50), and a random selection of cases across the Day 2–30 (34/50) data set. We used the Gold Standards Framework (GSF) as a prognostic tool, by use of the intuitive “surprise question” (“would you be surprised if this person died within the next days, weeks, months?”) and the disease-specific Prognostic Indictors (PI). Results Using the GSF we (retrospectively) predicted death in 94% of the Day 1 deaths and 63% of the Day 2–30 deaths. There was evidence of ACP in 32/50 patients (64%), predominantly in the form of a DNAR CPR (61%). There was very little evidence of other forms of ACP. Readmissions were justified on the basis of a medical condition in 100% of cases; this was infective in 60% (30/50). There were few interactions with secondary care in the 12 months prior to death (mode was 2 admissions in the month prior to death, 4 in the 12 months prior to death). Conclusions We must consider our discharge processes and medical decision making at the front door. A Prognostic indicator Tool would be useful to focus medical decision making. We must recognise infections as end stage disease in advanced ill health, including advanced frailty. We need to consider how we facilitate meaningful involvement of older people in their medical care towards the end of life.