Medical Assessment Unit Research Articles

Development of a Hospital Wide Inpatient Frailty Screening Pathway in a Model-2 Hospital

Abstract Background Our model-2 hospital is experiencing a higher proportion of frail older adults presenting to our medical assessment unit (MAU) and via direct ward admissions. Frailty increases the risk of co-morbidity, falls and mortality during hospital admission. Screening for frailty a point of admission allows early identification of these patients who are at higher risk of adverse outcomes. Early frailty screening also assists healthcare professionals with multidisciplinary team (MDT) management and treatment plans. Our hospital frailty committee established a frailty screening pathway for all inpatients aged 75 years and older to screen for frailty and minimise the risk of adverse outcomes secondary to frailty. Methods A hospital wide consultant chaired frailty committee was established with stakeholders from the MDT. Two separate screening pathways were developed, one for MAU admissions and one for direct ward admissions. A standardised frailty policy and standardised operating procedure (SOP) with algorithm illustration were compiled. Hospital wide education emphasised the development of a bespoke Clinical Frailty Score (CFS) sticker in conjunction with referral pathways to the newly established Clinical Nurse Specialist (CNS) For The Older Adult. In each pathway CFS-screening is completed for adults ≥75years at first-point of contact using the CFS, a score ≥6 triggers onward referral, CNS for inpatient and public health nurse for MAU discharged patients. Results Both pathways are established and used effectively and routinely on a daily basis. Associated educational sessions have emphasised the importance of frailty in our inpatient cohort. Conclusion The developed algorithms have been useful for identifying frailty and improving patient care with onward CNS referral. Future audits will assess effectiveness of screening and support advancement of frailty committee objectives via supporting business cases for resourcing.

An Audit of Time to Inpatient Bed In Patients With A Suspected Delirium

Abstract Background Our local Dementia/Delirium Combined Pathway and Care Bundle for Emergency Department (ED) and Acute Medical Assessment Unit sets a target door to ward admission in patients aged over 65 years with a suspected delirium at less than 6 hours. This audit assessed if this target is being met in patients with a suspected delirium. Methods Retrospective point prevalence audit of 240 randomly selected patients who were assessed by the Frailty Intervention Team (FIT) in the Mater Misericordiae University Hospital ED in 2022, aged ≥ 65 years with a suspected delirium (4AT ≥4) and no delirium (4AT=0). Time of presentation to ED, time of admission to ward bed, ward name and length of hospital stay were recorded. Results The median age in patient's with a 4AT ≥4 was 86 years (range 65-99). There was an equal spread across gender groups in patient's with a 4AT ≥4; 55.3% (n=52) females and 44.7% (n=42) male. The median wait time in ED for patients with a 4AT ≥4 was 25.26 hours (range 6.75-83.73) vs 21.65 hours (range 5.98-50.53) in patients with a 4AT=0. Only 19% (n=18) of patients with a 4AT ≥4 were admitted to a Specialist Geriatric Ward. The mean length of stay in patients with a 4AT ≥4 was 28.457 days vs 14.132 days in those with a 4AT=0 (p value=0.002, Mann-Whitney U test). Conclusion Older adults with a delirium spend prolonged periods of time in the ED. We are not meeting our local target of 6 hours from ED presentation to ward bed. Length of hospital stay is prolonged in patients with delirium. Our aim is to create a dedicated delirium bed on our Geriatric Specialty Ward so that we can provide delirium specific care and reduce overall length of hospital stay.

Community Flexible Endoscopic Evaluation Of Swallowing (FEES): A Prospective Cohort Study Of Clinical, Process And Patient-Reported Outcomes

Abstract Background Dysphagia prevalence increases with age, impacts on quality of life and increases healthcare utilisation and cost (Atrill 2018). Instrumental swallowing assessment is essential for accurate diagnosis and treatment of dysphagia but can be difficult to access in the community. FEES is a gold-standard instrumental assessment delivered by speech and language therapists (SLTs). The aim of this abstract is to report clinical, process and patient-reported outcomes of participants who had a community FEES over a 6-month period. Methods A prospective cohort study recruiting adults who accessed community FEES in Ireland's Mid-West. Baseline assessment data (demographics, a range of validated tools and process data) were recorded at index visit. A structured phone interview was completed at six months. The primary outcome was the rate of medical complications potentially caused by dysphagia at follow-up. Secondary outcomes included healthcare utilisation, dysphagia severity, functional status and quality of life. Results 62 participants were recruited: mean age: 70.98 (SD=15.01), 55.4% were female. At follow-up, 27.42% reported medical complications potentially attributable to dysphagia, 27.4% had attended general practice, 3.23% attended medical assessment units, 6.45% attended emergency departments. 82.26% were diagnosed with dysphagia or modified independence: Dysphagia Outcome Severity Scale (DOSS) ≤6, (M=5.2, SD=1.53). Changes to dysphagia care plans were recommended in 60.94% of cases. There was significant difference in Functional Oral Index Scale (FOIS) scores across time, F (1.75, 106.78) = 5.38, p = 0.008. FOIS scores at 6 months (M=5.92, SD=1.50) were significantly higher than pre-FEES (M=6.42, SD=1.37). Significant differences in quality of life (EQ5D5L-VAS) scores p<0.001 were detected: higher scores at 6-months (M=69.35; SD=20.42) compared to index visit (M=64.52; SD=19.44). Conclusion Access to community FEES for older persons may improve outcomes by reducing the frequency of dysphagia-related complications and healthcare utilisation, improving functional swallowing status, enhancing quality of life and contribute to evidence-based dysphagia diagnosis and care planning.

An Exploration Of Delirium Awareness Amongst Clinical Staff Working On The Acute Floor Of A Level Three Hospital

Abstract Background Delirium is an acute change in cognitive function that has an organic cause and is likely to be reversible or preventable (HSE Delirium Algorithm, 2021). The Frailty Intervention Team (FIT) based in the Emergency Department (ED) & Acute Medical Assessment Unit (AMAU) comprises of Physiotherapy, Occupational Therapy and Dietetics and is supported by an Older Persons Advanced Nurse Practitioner. The 4AT delirium screen is routinely completed by FIT as part of Comprehensive Geriatric Assessment. FIT observed limited use of delirium screening in ED/AMAU therefore we proposed to explore delirium awareness amongst all clinical staff on the acute floor. Methods All clinical staff in ED/AMAU were invited to complete an anonymised paper questionnaire to explore their awareness of delirium. Basic statistical analysis of data was completed using Excel. Results Over one week twenty-four questionnaires were completed by medical, nursing, allied health and health care assistants. Six questions explored delirium awareness and a seventh question explored the willingness to engage in delirium information sessions if made available to staff locally. On assessment of delirium awareness an average score of 79.3% (range 16.7%-100%) was achieved. Participants scored strongly on potential causes of and screening for delirium. Questions relating to delirium symptoms and potential outcomes of unrecognised delirium had the least correct response rates. 100% of respondents expressed interest in attending delirium information sessions if made accessible to them within ED/AMAU. Conclusion This study identified overall satisfactory delirium awareness amongst clinical staff on the acute floor and all participants expressed interest in expanding their knowledge in this area. Compliance with use of delirium screening tools in clinical practice was not assessed and we also acknowledge the limited number of participants. Future plans include audit of the use of delirium screening tools, delivery of delirium information sessions and provision of accessible delirium resources in ED/AMAU.

Implementation of the admission transfer unit to reduce emergency department boarding: A quality improvement initiative.

Emergency Department (ED) boarding crowds the emergency department, strains resources, leads to higher hospital costs, and is associated with increased morbidity/mortality, a negative patient experience, and patient adverse events. The time Ontario patients wait in emergency departments for inpatient beds continues to rise, with the average time admitted patients spend in the ED increasing between 2015 and 2019 from 13.8hours to 16.2hours. As reported in this quality improvement initiative, one potential solution is to repurpose short-stay medical assessment units for complex admitted medicine patients using an objective patient selection tool. Objectively selecting admitted ED patients with the highest risk for adverse events and prioritizing them to move to a transitional unit advances safe quality patient care and decreases Time-to-Inpatient Bed (TIB). Results from this quality improvement initiative include reducing the organization's TIB by 13hours.

Discharged from the emergency department following hospital-presented self-harm: referral patterns and risk of repeated self-harm

BackgroundPresentation to the emergency department (ED) with self-harm provides an important opportunity for intervention.AimsTo investigate characteristics and self-harm repetition risk of those discharged from the ED without a referral for mental health–related aftercare.MethodData on consecutive self-harm presentations to EDs for the years 2013–2019 (n = 55,770) were obtained from the National Self-Harm Registry Ireland. Multilevel Poisson and Cox regression models were estimated.ResultsHalf of the self-harm presenters were discharged from the ED (49.8%) and almost half of them did not receive a mental health–related referral (46.8%). Receipt of a psychosocial assessment was associated with a 50% reduced risk of non-referral (IRR 0.54; 95% CI 0.51–0.57). Non-referral was also less likely for young people (< 18 years), presentations involving attempted hanging, persons with previous self-harm presentations, and in the latter half of the study period (2017–2019 vs. 2013–2016), but was more likely for those brought by ambulance, presenting outside 9 am–5 pm and admitted to an ED medical assessment unit. Of those not referred, 19.3% had a repeat presentation within 12 months, compared to 22.4% of those referred. No difference in repetition risk between these two groups was evident in adjusted analyses. Self-harm history had the strongest association with repetition, with highest risk among individuals with four or more previous presentations (HR 9.30, 95% CI 8.14–10.62).ConclusionsThe findings underline the importance of assessing all individuals who present with self-harm and highlight the need for comprehensively resourced 24hr services providing mental health care in the ED.

Impact of first-line dalbavancin for cellulitis on hospital admissions and costs: A case series

BackgroundMany patients with cellulitis are treated with oral antibiotics as outpatients, but some require hospital admission for intravenous antibiotics. During the coronavirus disease 2019 pandemic, Betsi Cadwaladr University Health Board in Wales approved use of dalbavancin as first-line intravenous antibiotic from April to December 2020 to facilitate early discharge and prevent hospital admission. ObjectivesTo report cost savings and admission avoidance through first-line intravenous use of dalbavancin for cellulitis in one health board in Wales. Patients and methodsPatients with cellulitis who presented to the emergency department or medical assessment unit at Betsi Cadwaladr University Health Board's two hospitals between April and December 2020 were identified for treatment with dalbavancin, because they had not responded to oral antibiotics or their initial presentation warranted intravenous antibiotics. Patients received 1500 mg dalbavancin by intravenous infusion according to prescribing information and were sent home without being admitted. Outcomes were admission within 30 d of dalbavancin and cost savings from avoiding admission. Results31 patients were treated with dalbavancin for cellulitis in the emergency department or medical assessment unit. No patient was admitted within 30 d of receiving dalbavancin. Use of dalbavancin is estimated to have saved 248 bed-days over the study period, with an estimated saving of $120,444.23 based on avoidance of admission. The cost of dalbavancin for these 31 patients was $69,959.08, giving an overall cost saving of $50,485.15 ($1529.95 per patient). ConclusionsPrescribing dalbavancin as first-line intravenous antibiotic for cellulitis prevents admission, saving bed-days and admission-related costs.

Emergency presentation of colorectal cancer in older adults: A retrospective cohort analysis

IntroductionAdults aged 70 years and over account for almost 60% of colorectal cancer (CRC) diagnoses in the United Kingdom. Whilst emergency presentation of CRC is known to be associated with poorer outcomes across all ages, older adults are less likely to be treated with curative intent and have poorer overall survival (OS). We aimed to investigate whether presentation, management, or outcome differed in older (≥70 years) versus younger (<70 years) adults in our population. Materials and MethodsThe electronic records of patients diagnosed with CRC within the period 2016 to 2019 in National Health Service (NHS) Tayside, Scotland were retrospectively analysed. Patients were grouped by age (<70 years and ≥70 years). Demographics were compared by Chi-squared or t-test, and Kaplan-Meier and Cox proportional hazard regression were used for survival analyses. ResultsIn total, 1245 patients were diagnosed with CRC (median age 71 years, range 20–98). Of these, 215 patients (17.3%) presented emergently and were included in the analysis. Older adults accounted for 65.1% (n = 140) of emergency presentations. Older adults were less likely to present with classical symptoms of CRC (80.0% vs 90.7%, p = 0.04) and more likely to present via the medical assessment unit (46.4% vs 30.7%, p = 0.03). Additionally, older adults were less likely to receive a histological diagnosis of CRC (71.4% vs 97.3%, p < 0.001) or have complete staging investigations performed (78.6% vs 96.0%, p < 0.001). Fewer older adults underwent surgical management (55.0% vs 86.7%, p < 0.001) and fewer were treated with chemotherapy (14.3% vs 69.3%, p < 0.001). Whilst older adults had poorer median OS than those aged <70 years (12.0 vs 34.4 months, p < 0.001), multivariate Cox proportional hazards regression demonstrated that higher stage (stage III hazard ratio [HR] 2.7, 95% confidence interval [CI] 1.6–4.7, stage IV HR 16.7, 95% CI 9.7–28.8, incomplete HR 8.2, 95% CI 4.6–14.7) and not receiving chemotherapy (HR 2.6, 95% CI 1.7–4.0) were associated with poorer survival, whereas age and sex were not. DiscussionEmergency presentation of colorectal cancer was more common in older adults. Older adults were more likely to present atypically, less likely to have completed staging, and had lower rates of intervention, which were associated with poorer survival outcome.

The importance of prognosis in geriatric patients attending the emergency department: a comparison between two common short geriatric assessment tools

BackgroundThe use of short geriatric tools in the emergency department (ED) is increasing, but the literature is still conflicting. The aim of this study is to compare the precision and the accuracy of two short geriatric assessment tools to predict mortality in a cohort of older patients attending the ED.MethodsA retrospective study was conducted including patients ≥ 65 years, attending the ED and transferred to a medical assessment unit from February to July 2022. Clinical Frailty Scale (CFS) and Brief Multidimensional Prognostic Index (Brief MPI) were administered. The association between Brief MPI and CFS and mortality was analysed via area under the curve (AUC) with its 95% confidence intervals (CIs), the C-statistics and a multivariate Cox’s regression analysis, in the latter case reporting the data as hazard ratios (HRs) with their 95% CI.ResultsAmong the 579 patients enrolled (mean age: 77 years), both Brief MPI and CFS showed a good accuracy in predicting mortality (AUC: 0.72; 95% CI: 0.61–0.83 for Brief MPI; 0.754; 95% CI: 0.65–0.83 for CFS). The discrimination of Brief MPI and CFS in predicting mortality was excellent, since the C-index of the Brief MPI was 0.85 and of CFS = 0.84. In the multivariate analysis, the risk for mortality was significantly increased for frailer subjects (HR 4.65; 95% CI: 1.45–15.00 for Brief MPI > 0.66; HR = 9.24; 95% CI: 1.16–76.90 for CFS > 6).ConclusionsBrief MPI and CFS showed a good accuracy/precision to predict mortality in older patients attending the ED. Considering that they are quick to perform, their introduction in ED clinical practice could be extremely helpful.

245 ‘Pad culture: the use of continence wear in older people in an Irish University Hospital’

Abstract Background Incontinence in hospital patients can result in a longer length of stay, a greater risk of being discharged to a residential care setting, as well as increased healthcare and personal costs. Older adults may find it difficult to regain continence post discharge contributing to caregiver strain, social isolation and functional decline. There is evidence to suggest that there is an over-reliance on continence aids (wearable absorbent ‘pads’ &amp; urinary catheters) for older adults in hospital. The aim of this study was to assess the prevalence of continence aids among older in-patients in an Irish University Hospital, as part of wider service improvement project. Methods Data was collected on consecutive in-patients 65 years or older on a single day. Medical, surgical, oncology, coronary care and medical assessment unit were included. Current incontinence aid usage and pre-admission continence aid usage was recorded, along with demographics and current mobility status. Results 156 older adults were included. 53.5% were male and the median age was 81. A total of 57.4% (N = 89) of older patients were wearing disposable pads. Of these, 64.5% (N = 58) were not wearing continence pads pre-admission. A total of 23.2% (N = 36) had a urinary catheter inserted. Of these, 91% (N = 33) did not have a urinary catheter pre-admission. 38.3% (N = 61) of those wearing pads could mobilise either independently or with assistance of one. We also found a direct correlation between pad use and length of stay. Conclusion This study highlights the high prevalence of continence aid deployment in the care of older adults admitted to an acute hospital, with conversion to an aid occurring even in those who are able to mobilise independently or with supervision. Continence care and rehabilitation may benefit from inter-disciplinary assessment and management, similar to other complications of ageing and hospitalisation, such as delirium.

187 Prospective study of patients admitted to a model 2 hospital

Abstract Background Model 2 hospitals provide in-patient and out-patient care for differentiated, low-risk medical patients, who are not likely to require full resuscitation. Smaller hospitals are generally very well regarded by the local population and general practitioners. Methods This is a prospective descriptive study. Data were collected from all patients admitted via the Medical Assessment Unit (MAU) or stepped-down from a model 4 hospital for six consecutive weeks. Data points included: route of admission, age, Rockwood Clinical Frailty Scale (CFS) on presentation, length of stay (LOS), long term care/community resident, if delirium was present, known cognitive impairment, number of medications, hospital admissions in the past year and discharge destination. Results 144 patients were recruited to the study—79 via the MAU, 64 stepped down from a model 4 hospital and 1 via outpatient clinic, 95 of whom had a hospital admission within the previous year. The average age of patients was 72 years with a mean CFS of 4. 38% of patients were felt to be delirious on presentation to hospital, with 14% having a formal diagnosis of cognitive impairment prior to admission. Over 80% of patients were prescribed 5 or more medications in the community. Average overall LOS at the module 2 hospital was 9 days; 8 days for patients admitted via the MAU and 12 days for those stepped down from a model 4 hospital. The mean LOS at module 4 hospital prior to transfer was 6 days. 92% were living in the community prior to admission, 82% of which returned home. Conclusion Model 2 hospitals are a vital resource, particularly catering for the geriatric population. Patients are often multimorbid and admissions are often complicated with polypharmacy, delirium and discharge planning. Further exploration is required to assess how best to appropriately staff and resource them.

58 Review of a pilot Reablement Team service

Abstract Background A Reablement Team (RT) was established in a level two hospital for patients who are medically fit for discharge from either Medical Assessment Unit (MAU) or in-patient care, to prevent hospital admission and to support early discharge, through the provision of home rehabilitation. The team consists of senior grade medical social worker, occupational therapist, speech and language therapist, physiotherapist and a rehabilitation assistant. Intensive rehabilitation is provided in the home for up to 6 weeks. This study sought to evaluate service impact and performance in 2022. Methods A mixed method design was employed. Quantitative data was used by analysing number and nature of patients seen, discharge outcomes and pre and post outcome measures to determine goals achieved, quality of life and independence levels. Qualitative data included patient satisfaction questionnaires. Results In 2022, 78 patients were seen, 41 female and 37 male. Mean age of 79 years. Of the total number of patients, 59 (76%) were discharged early from hospital and 19 (24%) avoided hospital admission after attending the MAU. Underlying diagnosis of patients comprised Stroke (n = 29), progressive neurological disorders (n = 11), respiratory disorders (n = 2) orthopaedic/musculoskeletal (n = 13), falls (n = 20), patients medically unwell (n = 3). Of the patients discharged, 86% remained at home (n = 67), while 14% were readmitted. Using pre/post outcome measures, 89% reported an improvement in quality of life as measured by the ICECAP assessment and the mean increase of all patients in independence was 5.4% measured on the modified Barthel index. 91% of patients achieved one or more primary rehabilitation goals. All patients rated service satisfaction as high. Conclusion Findings indicate that a RT service can reduce LOS and prevent unnecessary admissions when intensive rehabilitation is provided by a dedicated team of HSCPs in the home. Additional benefits include reduction of primary care waiting list and integrated home care.

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

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

New care pathway to enable ambulances transfer patients to a model 2 hospital medical assessment unit.

Reconfiguration of the Irish acute hospital sector resulted in the establishment of a Medical Assessment Unit (MAU) in Mallow General Hospital (MGH). We developed a protocol whereby certain patients deemed to be low risk for clinical deterioration could be brought by the National Ambulance Service (NAS) to the MAU following a 999 or 112 call. The aim of this paper is to report on the initial experience of this quality improvement initiative. The Plan-Do-Study-Act (PDSA) Cycle for quality improvement was implemented when undertaking this project. A pathway was established whereby, following discussion between paramedic and physician, patients for whom a 999 or 112 call had been made could be brought directly to the MAU in MGH. Strict inclusion and exclusion criteria were agreed. The protocol was implemented from the 1st of September 2022 for a 3-month pilot period. Of 39 patients discussed, 29 were accepted for review in the MAU. One of the 29 accepted patients declined transfer to MAU. Of 28 patients reviewed in the MAU, 7 were discharged home. One patient required same day transfer to a model 4 centre. Twenty patients were admitted to MGH with an average length of stay of 8days. Frailty and falls accounted for 7 of the admissions and the mean length of stay for these patients was 12days. Our results have demonstrated the safety, feasibility and effectiveness of this pathway. With increased resourcing, upscaling of this initiative is possible and should be considered.

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

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

Under Pressure–TrolleyGar, a Metric Reflecting a Hospital System at Crisis-Capacity

Introduction:Health service capacity has been an issue in Ireland since the 1980s swinging cuts. Government reports from 2003 have consistently identified a requirement for 3,000-5,000 extra beds on top of the current approximately 10,500 capacity. Acute hospital bed capacity issues have escalated, the formal system of recording “over capacity” patients or “patients on trolleys” has developed. A “Trolleygar” reports issues from the Health Service Executive (HSE) three times daily. This count is an underestimate as patients temporarily housed in day care units, surgical, or medical assessment units, discharge lounges and other clinical areas which have a bed space are not counted in this overcapacity measure. This study's aim is to calculate the annual number of days on which no patients were lodged on trolleys in Wexford General Hospital.Method:Descriptive study using anonymized freely available data from the national HSE Trolley GAR reports on trolley patients in Wexford General Hospital from January 2019 until September 2022. A Golden Zero trolley day was stated as a day on which there were no reported trolley-patients at the three time points, Silver Zero trolley day when two of the time periods recorded no trolleys and a Bronze Zero Trolley day when one period recorded a zero trolley count.Results:Data was collected on 1,369 days, with 90 days excluded due to missing data sets. There were 162 Golden days recorded (12.67% of total days). The year 2020 recorded the highest number of Golden days at 28.69% (105 days), followed by 2021 with 11.23% (41 days). During 2019 there were 3.84% (14 days) Golden days and 2022 had the lowest number (January-September) with 0.73% (2 days).Conclusion:Despite a zero-tolerance policy, Golden days are disappearing rapidly, capacity is urgently required with post-pandemic ED attendance surges worldwide. True recording of overcapacity patients is required for appropriate capacity modeling.

1209 A TEACHING PROGRAMME TO IMPROVE RATES OF DELIRIUM SCREENING ON THE MEDICAL TAKE

Abstract Introduction NICE Clinical Guideline CG103 states that adults aged 65 and older should be screened for delirium within 48 hours of emergency hospital admission. The Geriatric Medicine Research Collaborative (GeMRC)'s World Delirium Day data from 2019 showed an average screening rate of 27% nationally. After an inpatient fall on the Medical Assessment Unit resulted in hip fracture for a patient who had not been screened for delirium with the recommended 4 A's Test (4AT), we decided to collect data on screening rates and devised a way of improving these. Method Baseline data was collected examining patient notes of adults over 65 years currently on the Medical Assessment Unit who had been seen by a doctor. The intervention was a teaching session on delirium for the junior doctors on the ward, focusing on the adverse prognostic features of delirium and importance of clear diagnosis with onward communication to the patient's GP. Repeat data collection was done following this. Results 55% of all patients on the ward throughout data collection were over 65 years of age. A total of 79 patient notes were examined. The baseline rate of delirium screening with a completed 4AT pre-intervention was 25%. Post-intervention this increased to 41.3%. Without further education this fell to 26.9%. Most of the unscreened patients showed incomplete 4ATs or only the Abbreviated Mental Test (AMT) section completed. Conclusion Integrating delirium teaching into departmental teaching on Acute Medical Units can increase the rates at which delirium is diagnosed, which is important for the patient's clinical trajectory and prognosis, both for their inpatient stay and long term. Further work is required to show sustained improvement. Future work may include assessing the rate of documented diagnosis out of those who clinically fit the criteria.

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

Abstract Introduction The medical intake at Morriston Hospital is accepted on two units; Rapid Assessment Unit (RAU) and Acute Medical Assessment Unit. Both were acute physician-led until July 2021 Method (Phase 1). From July 2021, RAU became geriatrician-led (Phase 2). This evaluation concerns the performance of RAU. Phase 1 (Acute Physician-Led Unit) Between 01/08/2020-30/06/2021, there were 3102 admissions with a median length of stay (LOS) of 2 days on RAU. 37.2% of patients were discharged directly from the unit. (SBUHB data). A detailed analysis of 496 patients consecutively assessed between November 2020–January 2021 showed a median LOS on RAU of 1, 28.8% were discharged directly from RAU. Overall health board (HB) median LOS for the cohort was 7. In over 70 years, median LOS on RAU was 1, overall HB LOS 9. Phase 2 (Geriatrician-Led Unit) 1237 patients were assessed July-December 2021, with a median LOS of 2 days. 42.8% of patients were discharged from RAU. (SBUHB data). A detailed analysis of 566 patients consecutively assessed between September-November 2021 showed a median LOS on RAU of 2, 41.7% discharged directly from RAU. Overall HB median LOS for the entire cohort was 5. For the &amp;gt; 70 years, median LOS on RAU was 2, overall HB LOS was 7. Patient flow through assessment areas is dependent on the function of downstream medical wards. Mean LOS within medicine at Morriston increased 1.5 days between Phase 1 and Phase 2. Results Acute geriatricians have delivered the 72hr LOS standard that SBUHB has set for assessment areas. The unit has achieved a reduction in overall LOS for the cohort of patients evaluated (p&amp;lt;.01), especially for the &amp;gt; 70 years (p=.007). Conclusion This data supported a change in practice; RAU has taken a frailty specific intake since January 2022.

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

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

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

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