NICE Quality Standards Research Articles

P034 Results of first survey of NRAS SMILE-RA e-learning programme users

Abstract Background/Aims An important but insufficient aspect of care in people with inflammatory arthritis (IA) is empowering patients to acquire good understanding of their disease and building their ability to deal effectively with the practical, physical and psychological impacts of it. The ability to self-manage in inflammatory arthritis (IA), with the right support (including from patient organisations), represents an essential component of care that goes beyond drug therapy and supports the patient in managing these impacts. In July 2021, EULAR Taskforce published Recommendations for Self-Management strategies in patients with Inflammatory Arthritis. Co-Convenors of the Taskforce were Ailsa Bosworth, NRAS and Elena Nikiphorou, King’s College Hospital. NICE quality standards also relate to provision of education and self-management resources. In September 2021, NRAS launched their unique e-learning programme SMILE-RA (self-management individualised learning environment). After launch, the first goal was to get a sufficient body of people using the programme in order to determine whether our key aims for each of the modules were being met. The first survey of participants took place in late summer 2022. Methods A survey with 21 questions was developed using Sogolytics on subjects including: navigation and ease of use, what people had learnt/gained from each module. The survey was emailed on 11 Jul, 2022 to 913 people who had registered for SMILE-RA. A follow up reminder was sent on 18th of July 2022. The survey closed on 15th of August 2022. 132 responses were received representing a response rate of 14% Results • Majority of respondents heard about SMILE through NRAS, only 10% through their rheumatology team. • Nearly 80% think length of the modules is just right • 86% think that the links to other resources, whether NRAS or external, are extremely (majority) or quite clear and helpful • 68% had increased their knowledge of their disease • 72% had increased their understanding of the importance of self-management • 62% had increased their knowledge of medicines used in the treatment of RA • 84% would recommend SMILE to another person. Conclusion These initial results from the first survey of users indicate a very high proportion of people are achieving the learning objectives of each module and are improving their understanding of their disease and how to self-manage their condition better. NRAS will build on this feedback and these results to target resources where they are most needed. These results are particularly interesting and important in the light of the move to put stable patients onto patient-initiated follow up pathways where consultations with their team are set for an interval of up to 2 years. Building patients’ knowledge of their disease, how to manage symptoms and their confidence to self-manage between appointments will improve health outcomes. Disclosure A. Bosworth: None. C. Jacklin: None.

Fetal Alcohol Spectrum Disorder and Neuropsychology: Exploring the implications of new NICE quality standards (2022) for neuropsychologists through a pilot assessment service

Recently released NICE Quality Standards for the assessment and diagnosis of Fetal Alcohol Spectrum Disorder (FASD) in children and young people emphasise neuropsychological assessment as an important part of the process. However, for many areas of England & Wales this may not be in line with current service provision. We conducted a scoping study of services within Oxfordshire to understand the current support available for children with possible FASD. In addition, we offered a pilot neuropsychology assessment service for seven children referred by a Community Paediatrician. We found that many services across Oxfordshire work with children who they suspect to have FASD, but no service offers FASD assessment or specific intervention. A trial neuropsychology service confirmed evidence for significant heterogeneity within this population, and therefore the need for careful, hypothesis driven assessment, to which neuropsychologists are well-placed to contribute.

685 Management of Patients Presenting Acutely with Suspected Ureteric Colic

Abstract Aim To assess how patients presenting with suspected ureteric colic are managed compared to NICE guidance (renal and ureteric stones, QS195 July 2020). Also, to review the incidence of ureteric stones occurring in all referrals received in a hospital where patients are referred prior to imaging confirmation of stones. Method The dataset was formed by retrospective handover screening during a three-month period in 2019 prior to the impact of COVID-19 with any patient included who was referred to urology with a suspected ureteric calculus, generating 149 cases. Demographic information, imaging modality and treatment were recorded as well as comparisons to five NICE quality statements on the management of ureteric stones. Results Of the 149 referrals 88 were male with a median age of 45 years. Ureteric stones were found in 61/149 of referrals with 99/149 receiving CT scan first line whilst the remainder were initially imaged using ultrasound. Forty referrals were received for women under the age of 50 with only 3/40 having a ureteric stone. Pick-up rate of ureteric stones was higher in older and male patients. CT within 24 hours of referral was achieved in 82.8% and 69.9% were given appropriate analgesia. In patients in which it was necessary primary treatment occurred within 48 hours in 45.4% of patients. Conclusions Less than half of referrals received had a ureteric stone with particularly low pick-up rates in young women. A large proportion of patients having ultrasound first line had subsequent CT imaging. Adherence to NICE quality standards was comparable to other centres.

Paediatric Psychosocial Emergencies in Two Inner-City London Hospitals: Review of the Current Management and Critical Evaluation Using NICE Self-Harm Quality Standards (QS34)

AimsThe paediatric wards support many children presenting with psychosocial crises. This has been increasing in recent years. NICE quality standards recommend that children who have self-harmed receive: a comprehensive psychosocial assessment, are assessed within 24 hours of referral if at high risk of suicide, a collaboratively developed risk management plan and monitoring to reduce risk of further self-harm. We aim to measure the number of referrals made by hospitals for acute psychiatric presentations and the adherence to the above quality standards by the Service for Adolescent and Families in Enfield.MethodsWe retrospectively audited inpatients referred by North Middlesex hospital and Barnet hospital. Referral data were collected over 5 years. Data collected between April 2018 and March 2019 were evaluated to review good practice and adherence to the NICE quality standards. For each patient, we collected data on whether they have had a comprehensive psychosocial assessment, if the assessment was completed within 24 hours, 7-day follow-up review and a documented risk assessment.ResultsThere has been a 141% increase in hospital referrals to the service from 2014/15 to 2018/19. The service had 130 referrals between April 2018 and March 2019. 72% of referrals came from North Middlesex hospital and 28% were from Barnet hospital. Ages were between 5 and 18. Girls formed 74% of all presentations. 87% of patients presented with deliberate self-harm, suicidal ideation or suicide attempt. Of all referrals 100% had a comprehensive psychosocial assessment, 93% were seen within 24 hours of being referred, 97% had a documented risk assessment and 92% had a 7-day follow-up review.ConclusionSelf-harm and suicidal ideation in children are rising, especially among girls aged 13 to 16 years (increased by 68% between 2011 and 2014). The gender inequality in our referrals further supports these findings. Higher rates of self-harm have been shown in more deprived areas and could be associated with gang involvement, bullying, abuse, gender identity and family issues. We have developed an assessment protocol and safety plan, are liaising with hospitals daily to arrange assessments and follow-up. Paediatric nurses have been trained in the time to talk programme and a full-time crisis liaison nurse has been employed. This will be re-audited to measure effectiveness of interventions.

Introduction to quality standards and indicators

The objective of this article is to describe NICE’s role regarding quality improvement in health and social care in England and to gain an insight into how NICE quality standards and indicators are used in the health and social care system. NICE is the national point of reference for advice on safe, effective, and cost-effective health and social care. NICE achieves this by providing advice aligned to the needs, uses, and demands of the resource constrained system. NICE’s role in quality improvement follows a stepwise progression starting with evidence-based guidance and recommendations through to quality standards and indicators. These are aimed to contribute to improved outcomes in health and social care.

P020 The impact of COVID-19: local observations from the National Early Inflammatory Arthritis Audit

Background/AimsThe National Early Inflammatory Arthritis Audit (NEIAA) has provided the opportunity for rheumatology services to benchmark the care they provide against NICE quality standards (QS)33. It has proven to be a powerful lever for improving quality and our department is testimony to this. Recruitment to all national audits was paused for several months due to the COVID-19 pandemic. Once pressures had eased we recognised that NEIAA would help to understand the impact of the pandemic on the diagnosis and initial management of patients with rheumatoid arthritis. Our department continued to see all new urgent referrals face-to-face and were fortunate that the team were not redeployed.MethodsData submitted to the NEIAA online tool during year 3 (September 2020-March 2021) were downloaded for analysis. Data from year 2 were downloaded for comparison.ResultsIn year 3, 154 patients were recruited to the audit compared to 268 in year 2. 36 (23%) had rheumatoid arthritis and were included in the follow-up cohort compared to 73 (27%) in year 2. All patients had a baseline and a 3-month follow up form completed, however 17 patients in year 3 had a telephone appointment at 3 months and there was no available DAS28. Patient demographics were similar. The case mix of patients recruited was also; in year 3, 41% were diagnosed with autoimmune inflammatory arthritis compared to 47% in year 2 and 42% with a non-inflammatory condition compared to 39% in year 2. In year 3, 41% of all patients were seen within 3 weeks of being referred and 58% of patients with RA started DMARD therapy within 6 weeks of referral. This compared to 54% and 56%, respectively, in year 2. In year 3, symptom duration prior to referral appeared longer: 31% had symptoms for less than 3 months, 31% for 3-6 months, 22% for 6-12 months and 16% for more than 12 months compared to 67%, 18%, 12% and 3%, respectively, in year 2. DAS28 at baseline was higher in year 3 with 47% high, 47% moderate and 6% low disease activity or in remission compared to 27%, 61% and 12%, respectively, in year 2. DAS28 at 3-months was also higher in year 3 with 16% high, 37% moderate and 27% low disease activity or remission compared to 6%, 25% and 69% respectively in year 2.ConclusionDespite the impact of the pandemic we have maintained our performance against QS2 and 3. However, patients seemed to have longer duration of symptoms prior to referral, higher disease activity at baseline and at 3 months. We await the 12-month data to determine 1-year outcomes, including escalation to high cost drug therapies.Disclosure E. MacPhie: Other; EM is the secretary of the North West Rheumatology Club, meetings have been supported by UCB, MSD, Abbvie and Lilly. L. Ashcroft: None. N. Foreman: None. S. GIlbert: None. S. Horton: None. A. Madan: None. K. Moon: None. C. Rao: None. S. Fish: None.

‘Adults with Parkinson's disease and hallucinations or delusions can have treatment with clozapine if they need to’

SUMMARYClozapine is the only antipsychotic licensed for treatment of Parkinson's disease psychosis (PDP) but is infrequently used in the National Health Service because of obstacles to the integration of hospital-based neurological/geriatric services with clozapine clinics run by community mental health teams. This commentary points out the mismatch between NICE quality standards on antipsychotic treatment for PDP and current clinical practice. It suggests that forthcoming integrated care systems should be able to overcome these obstacles, enabling innovative models for providing clozapine treatment for PDP such as those described by Taylor et al, so that clozapine treatment becomes a right for patients and their families.

884 Improving the Analgesia Prescribing Compliance to NICE Guidelines (NG118) In Suspected Renal Colic Patients Using a Proforma

Abstract Aim To improve analgesia prescribing for patients admitted with suspected renal colic in line with NICE guidelines (NG118) in an acute district general hospital using a proforma. Method In the first cycle, a retrospective review of 16 patients who presented with renal colic to the emergency department or surgical assessment unit was performed and the analgesia prescribing was recorded. A unique analgesia prescribing proforma was then developed using NICE guidelines (NG118) including the use of NSAIDS as first-line when there are no contra-indications, intravenous paracetamol, opioid analgesics and omitting antispasmodics. Following implementation of the proforma, a prospective review of 18 patients were included in the second cycle and the prescribing compliance were compared. Results Study included 34 patients who presented with suspected renal colic over a 3-month period. In the first cycle, 19% of patients had appropriate analgesia prescribed which were compliant with NICE guidelines. In cycle 2, 89% of patients had appropriate analgesia prescribed. In particular, the inappropriate prescription of antispasmodics has improved significantly (38 % in cycle 1 vs 0 % in cycle 2). Conclusions A proforma can serve as a useful ‘checklist’ for analgesia prescribing and improve the symptomatic relief for patients presenting with suspected renal colic in line with NICE quality standards.

524 QUALITY IMPROVEMENT PROJECT: INCORPORATING COMPREHENSIVE GERIATRIC ASSESSMENT INTO COMMUNITY HOSPITAL CLERKING

Abstract Elderly patients transferred to community hospitals often have complex medical, social, psychological, functional and pharmacological backgrounds that require careful assessment in order to create and deliver a high quality, patient-centred care plan. Unfortunately, time pressures experienced by staff in acute hospitals can make Comprehensive Geriatric Assessment (CGA) unfeasible for every patient. Moreover, junior members of the medical team may be unsure as to which aspects of a patient’s background and presentation constitute important elements of a CGA. Failure to recognise and document pertinent issues can lead to prolonged admissions, disjointed care and failed discharges. Admission to a community hospital presents a convenient ‘checkpoint’ in the patient’s hospital journey at which to undertake a CGA. Recording the relevant information in an effective clerking proforma when the patient is admitted ensures that this information is displayed clearly and in a way that is accessible to all members of the multidisciplinary team. The pre-existing clerking proforma at Amersham Community Hospital omitted several important elements of CGA (such as examination of feet and gait, assessment of mood, FRAX-UK score, creation of a problem list etc.) The aim of this quality improvement project was to create a thorough, yet user-friendly and time-efficient clerking proforma which incorporated the important components of CGA. Using BGS guidance and NICE quality standards, alongside suggestions from the medical team, the existing clerking proforma was adapted and reformed. After one month, feedback from the team was used to further improve the clerking proforma, ensuring that it was user-friendly, whilst meeting the standards set out by NICE and BGS. This was repeated as part of a second PDSA cycle. The improved clerking proforma enables junior doctors to undertake a thorough and holistic assessment, promoting efficient detection of issues and the delivery of a higher quality of care.

Audit on venous thromboembolism risk assessment in mental health inpatient wards

AimsFrom May 2015 NHS organisations in Wales are expected to report the number of VTE cases associated with hospital admissions which are possible hospital acquired thrombosis (HAT) per calendar month. NICE Quality Standards (QS3) recommend that All patients, on admission, receive an assessment of VTE and bleeding risk using the clinical risk assessment criteria described in the national tool.BackgroundVTE is a condition in which a blood clot (thrombus) forms in a vein, most commonly in the deep veins of the legs, known as a deep vein thrombosis (DVT). The thrombus can dislodge from its original site and travel in the blood (embolism). If it becomes lodged in the lungs, a condition known as a pulmonary embolism (PE) arises and can cause sudden death. Hospital acquired thrombosis is avoidable and unfortunately kills patients under our care.MethodCollected data using a standardised form for 131 patients from 3 inpatient mental health units on documentation of a VTE risk assessment in the inpatient notes. For those patients who had a documented risk assessment, further data were collected on documentation of contraindications, eisk factors, sign and date of prescription and the appropriateness of prescribing.Conclusion8% of patients from one mental health unit (n = 48) had a documented risk assessment in the notes. The subsections of documented risk assessment including contraindications, risk factors, sign and date of prescriptions and appropriateness of prescribing were complete at 100%. No patients from the other 2 mental health units (n = 39,44) had a risk assessment documented in the notes.Recommendations: All adult inpatients in Mental Health units must receive a venous thrombo-embolism risk assessment. This must be documented on the Inpatient Medication Chart. Consider adding a risk assessment checklist tool mapped from the Department of Health guidelines into the Mental Health Inpatient Clerking in pro-forma.

P016 When and how to deliver advice about self-management: local observations from the National Early Inflammatory Arthritis Audit

Abstract Background/Aims The National Early Inflammatory Arthritis Audit (NEIAA) provides the opportunity for rheumatology services to benchmark the care they provide against NICE quality standards (QS) 33. During the first year of the audit our focus, after being identified as an outlier, was on improving performance against QS2 and specifically reducing waiting times. This project assessed compliance against QS4: patients with rheumatoid arthritis (RA) are offered educational and self-management activities within 1 month of diagnosis. Methods Data submitted to the NEIAA online tool during the second year of the audit were downloaded for analysis. Results were presented initially to our National RA Society (NRAS) Patient Support Group and then together with feedback from the patients, to the Rheumatology Multi-Disciplinary Team. Driver diagrams were developed and areas for improvement identified. Results In total, 268 patients were recruited to the audit in year 2; 73 (27%) had confirmed RA and were included in this analysis. Follow-up data at 3 months was available for 56 patients (77%). Characteristics were: mean age 58 years (range: 19-88), 47 (64%) female, 34 (47%) working and 11 (15%) smoked. Forty-one patients (56%) started DMARD therapy within 6 weeks of referral. All patients with RA received written information at baseline about their condition. However, only 39 patients (71%) were documented to have been provided with advice about self-management at their 3-month follow-up. Feedback from the NRAS Group highlighted a number of important considerations. Firstly, that information about self-management needs to be given to the patient at the right time. Patients need to be ready to take advice on board and to have come to terms with their diagnosis. For many, trying to do this in the first 3 months of diagnosis was felt too soon. Information needs to be made available in different formats and tailored to the individual. Patients valued speaking to someone with a lived experience and felt this was more powerful than speaking to a healthcare professional to understand about self-management. Driver diagrams highlighted areas for improvement which included the importance of the team agreeing what is meant by self-management, using a patient activation measure to determine if the patient is ready to take on board this information, exploring different formats of delivery and utilising expert patients. Conclusion The NEIAA has again enabled the team to identify further areas for improvement. Involving patients in the discussion has provided a valuable insight into how we look to support our patients to live with their condition. It has also led us to question whether the QS is right to support that self-management advice is offered to patients within 1 month of diagnosis. Disclosure E. MacPhie: Other; EM is the secretary of the North West Rheumatology Club, these regional meetings have been funding by an unrestricted educational grant from UCB and are now sponsored by Abbvie. L. Ashcroft: None. J. Brazendale: None. N. Foreman: None. S. Gilbert: None. C. Greenall: None. S. Horton: None. I. Lewis: None. A. Madan: None. C. Rao: None. S. Fish: None.

P017 Out of outlier status: local observations from the National Early Inflammatory Arthritis Audit

Abstract Background/Aims The National Early Inflammatory Arthritis Audit (NEIAA) provides a powerful lever for driving up quality. Rheumatology services benchmark care against NICE quality standards (QS) 33. Notifications are sent out quarterly to Trusts at risk of being an outlier and outliers are identified in the annual report. After being named as an outlier, this project describes our journey to improve compliance against QS2 (patients are seen in a rheumatology clinic within 3 weeks of referral and QS3 (patients with rheumatoid arthritis (RA) are started on DMARDs within 6 weeks of referral). Methods Data submitted to the NEIAA online tool during year one were downloaded for analysis. Results were presented to the Rheumatology Multi-Disciplinary Team, the patient pathway was mapped, driver diagrams were developed by the team and areas for improvement identified and changes implemented. Data from year two were downloaded for comparison. Results In total 530 patients were recruited to the audit: 262 in year 1 and 268 in year 2. 77 (29%) in year 1 and 73 (27%) in year 2 had confirmed RA and were included in this analysis. All patients had a baseline form completed, and 61 (86%) and 56 (77%) had a 3-month follow-up form completed for year 1 and 2, respectively. The demographics were very similar for years 1 and 2. In year 1, 10% of all patients were seen within 3 weeks of being referred and 7% in the RA cohort started DMARD therapy within 6 weeks of referral. This compared to 54% and 56%, respectively, in year 2. Changes implemented relating to QS2 included referral guidelines for primary care, prompts when requesting rheumatoid factor and CCP antibodies and changes to the wording of antibody reports, increased triage capacity, simplifying the booking process and increased new appointment capacity (additional consultant, upskilling extended scope practitioner). QS3 changes implemented included increasing drug education and monitoring clinic capacity and improved sign-posting to National Rheumatoid Arthritis Society. Initial combination therapy was more prevalent in sero-positive patients and those with a high DAS28 during both years. In year 1, disease activity at baseline vs. 3 months was: remission/low disease activity in 8% vs. 54%, moderate in 45% vs. 39% and high in 47% vs. 7%. In year 2, rates at baseline vs. 3 months were: remission/low disease activity 12% vs. 69%, moderate in 60% vs. 25% and high in 28% vs. 6%. Conclusion Significant changes have been made which have resulted in an improvement in performance against QS2 and 3. Disease activity at baseline was lower, potentially as a result of seeing patients sooner and this has resulted in better outcomes for patients at 3 months. Ongoing data collection will allow the team to determine outcomes at 12 months. Disclosure E. MacPhie: Other; EM is the secretary of the North West Rheumatology Club, these regional meetings have been funding by an unrestricted educational grant from UCB and are now sponsored by Abbvie. L. Ashcroft: None. J. Brazendale: None. N. Foreman: None. S. Gilbert: None. C. Greenall: None. S. Horton: None. I. Lewis: None. A. Madan: None. C. Rao: None. S. Fish: None.

P06 Driving up quality: local observations from the National Early Inflammatory Arthritis Audit

Abstract Background The National Early Inflammatory Arthritis Audit (NEIAA) provides the opportunity for rheumatology services to benchmark the care they provide against NICE quality standards (QS) 33. It provides a mechanism to identify where improvements can be made. This project assessed compliance against QS2: patients are seen in a rheumatology clinic within 3 weeks of referral and QS3: patients with newly diagnosed RA should be offered short-term glucocorticoids and a combination of DMARDs within 6 weeks of referral. Methods Data submitted to the NEIAA online tool during the first year of the audit were downloaded for analysis. Results were presented to the Rheumatology Multi-Disciplinary Team. The patient pathway was mapped, driver diagrams were developed by the team and areas for improvement identified. Results In total 246 patients were recruited to the audit, 71(29%) had confirmed rheumatoid arthritis (RA) and were included in the follow-up cohort. All patients had a baseline form completed, and 61 (86%) had a 3-month follow-up form completed. The mean patient age in the RA cohort was 62 years (range: 26-88). Rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA) status was recorded in 69 (97%) and 63 (88%) respectively with, 33 (52%) positive for RF and 26 (38%) for ACPA. Twenty-two patients (8.9%) were seen within 3 weeks of being referred and 5 patients (7%) started DMARD therapy within 6 weeks of referral. On average, patients waited 66 days (range: 5-138) to be seen and diagnosed, and if sent for investigations on average a further 50 days (range: 37-69) to diagnosis. There was an additional wait for drug education, with patients waiting a mean of 25 days and 39 days if they had been sent for investigations to confirm diagnosis. Prior to starting DMARD therapy 65 (90%) patients were given bridging steroids. Sixty-five (92%) patients started DMARDs, and in those that didn’t there was justification. A higher proportion of patients >65years started DMARD monotherapy in sero-positive patients and those with a high DAS28 we found more use of combination DMARD therapy. Process mapping and driver diagrams highlighted areas for improvement, both clinician and patient in origin. Regarding QS2 these include developing referral guidelines for primary care, increasing triage capacity, simplifying the booking process, increasing new appointment capacity (additional consultant, upskilling extended scope practitioner and specialist nurse) and introducing text reminders. In relation to QS3 these include: one-stop clinic with access to ultrasound, increasing drug education and monitoring clinic capacity, improve sign-posting to National Rheumatoid Arthritis Society. Conclusion The NEIAA has provided detailed information about the patient pathway which has enabled the team to identify priority areas for improvement. The prospective nature of the audit will allow the team to determine if changes are improving performance. Disclosures J. Loh None. J. Withers None. S. FIsh None. E. MacPhie Other; EM is the secretary of the North West Rheumatology Club; meetings are supported by an unrestricted educational grant from UCB.

O21 Unrecognised inflammatory back pain: a retrospective review of people presenting to musculoskeletal physiotherapy with undiagnosed axSpA

Abstract Background Axial spondyloarthritis (axSpA) is commonly mistaken as chronic mechanical back pain. Delayed diagnosis averages 5-8 years with impacts on effective and timely management, outcomes and quality of life. Research on diagnostic delay suggests that a lack of recognition of inflammatory back pain and possible axSpA has been a contributing factor. Published referral criteria including NICE guidance (2017) and quality standards (2018) on spondyloarthritis in over-16s highlight the importance of earlier diagnosis and were developed to support earlier recognition and referral of suspected axSpA in primary care settings. This aim of this study was to investigate the occurrence of referral for musculoskeletal physiotherapy care and treatment prior to diagnosis of axSpA and to evaluate levels of recognition. Methods A retrospective review was undertaken of all patients diagnosed with axSpA who had been referred to and received physiotherapy care within nine physiotherapy services prior to diagnosis (1990-2016). Unrecognised axSpA was taken as the individual referred for and receiving three or more episodes of physiotherapy prior to diagnosis. Data was obtained on assigned diagnostic codes, number of episodes of physiotherapy care and contacts per episode. Results Two hundred and sixty three (263) people diagnosed with axSpA (age range 17-69 years) had been referred by a GP and received physiotherapy care prior to their diagnosis. Within this axSpA population, 103 (44%) had received 3 or more musculoskeletal physiotherapy assessments and episodes of care. Number of treatment contacts within each care episode ranged from 3 (47 people) to 58 contacts (1 person) [median=11 contacts-10 people]. Average time from initial physiotherapy care episode to date of diagnosis was 6.4 years (range=0.3-12.8 years, median=8.8 years). The most common assigned diagnostic code was back pain (49.6%), followed by shoulder (11.1%), knee (8.5%), neck (7.7%), ankle/foot (4.3%), tendonitis (4.2%), joint pain (3.4%), osteoarthritis (3.4%) and sacroiliac joint (2%). Analysis indicates that in nearly half of individuals who came to be diagnosed with axSpA, features of inflammatory back pain and possible axSpA were not recognised on at least six or more assessment occasions by either referrers or treating clinicians. Conclusion This study illustrates the extent of unrecognised axial spondyloarthritis referred to and missed in musculoskeletal clinical practice. This lack of recognition highlights the importance of professional education on signs, symptoms and risk factors for axSpA to support earlier diagnosis and treatment. Screening for and recognition of inflammatory back pain and other features for when to suspect and refer for possible axSpA in assessments of people with back pain need to be part of routine musculoskeletal clinical practice. Further research into contributors to diagnostic delay and the most effective education strategies to support earlier recognition of axSpA is needed. Disclosures C. McCrum: Honoraria; Novartis. K. Kenyon None. J. Cleaton None.

68 Urinary Catheterisation in Trauma and Orthopaedic Patients

Abstract Background The use of urinary catheterisation in neck of femur fracture patients is often debated as common best practice to manage and appropriate fluid assessment. Routine catheterisation increases the risk bacteraemia, genitourinary injury, worsening mobility, risk of pressure sores and predisposition to delirium and falls. There is a need for increased awareness of urinary catheterisation management in conjunction with healthcare-associated infections. NHS improvement has issued a letter aiming to half healthcare-associated Gram-negative bacteraemia, the majority of which is catheter-related. This project aims to identify barriers to safe catheter care in the orthopaedic population; by determining if management of urinary catheters is complaint with NICE quality standards (QS61). Introduction Appropriate perioperative care can help manage the associated risk of neck of femur fractures. The British Hip Society and British Orthopaedic Association have provided little guidance on postoperative care and risk management. Appropriate catheter care will improve overall patient care but reducing mortality and associated morbidity, by shortening stay by early mobilisation and management of complications. Methods All catheterised trauma and orthopaedic patients in a district general hospital over one month (February) were included 67% of which had sustained neck of femur fractures. Data from nursing and doctors’ records on the following parameters were collected: demographics, the reason of admission, indication/location for catheterisation and responsible clinician; the number of days catheterised, the reason for the retention of catheterisation and management of suspected/confirmed catheter-related infection. Data were collected in April following the implementation. Intervention A urinary care pathway was launched based on the HOUDINI algorithm and educational seminars for medical and nursing staff were conducted. Results Mean age of patients was 78. Initial data was suggestive of poor documentation and prolonged, inappropriate retention of urinary catheterisation and not in accordance with current guidance. Data was recollected in April after the launch of the pathway; data was indicative of marginal improvement of catheter care management, reduced time of catheter retention, improved documentation likelihood of review. Conclusions Incorporating a catheter care pathway in managing orthopaedic patients has shown improvement in the overall documentation and management of urinary catheterisation. Despite this improvement demonstrated, implementation of the pathway is still substandard. This pathway will be incorporated into an innovative integrated neck of femur pathway in June.

176 The Impact of Inter-generational Care on the Emotional Well-Being of Older Persons with Dementia Living in Long Term Care Settings

Abstract Background A significant number of older persons living with dementia highlight feelings of low mood following admission to care settings. There needs to be ongoing development in addressing the emotional well-being of this group as highlighted by 2013 NICE quality standard: Mental well-being of older persons in care homes. This exploratory study evaluates the impact of an inter-generational care group with emphasis on the emotional well-being of the older persons. A structured programme of shared experiences between the older persons group and pre-school age children was introduced. Methods Approval was sought from the safeguarding committee and insurance board of the care facility. Consent was obtained from residents to participate. Risk assessments were completed for the activities and the participants. Cognitive screen score and communication ability of each resident was noted in selecting the focus group (n=10). Outcome measures included qualitative interviews completed after each session. A qualitative mood wheel was completed with residents before and after the session had taken place. Results Focus group data supported the programme’s impact on emotional well-being. Eighty percent of participants reported mood elevation. Other benefits identified included excitement for the next session and bringing back memories of raising their own children and grandchildren. A singular negative aspect identified was that on occasion over stimulation impacted mood and participation level of one resident. Ninety percent of participants were female. The costs incurred were minimal to the organisation. Provision of resources were shared between the care facility and preschool facility. Conclusion The findings of this study support the use of inter-generational care groups in long term care facilities for residents with dementia. It confirms the benefits of improving emotional well-being of this cohort. Adequate supervision measures must be in place to regulate the stimulation level of the environment and facilitate individuals to exit the session.

National Diabetes Audits inform best practice for diabetes foot care and hospital inpatients

National Diabetes Audits inform best practice for diabetes foot care and hospital inpatients

267 Improving standards of care of axial spondyloarthritis through implementation of NICE Quality standards 170 across the South Coast Axial Spondyloarthritis Network

267 Improving standards of care of axial spondyloarthritis through implementation of NICE Quality standards 170 across the South Coast Axial Spondyloarthritis Network

Concurrent validity of the modified Patients Association Nutrition Checklist (PANC) against the ‘Malnutrition Universal Screening Tool’ (‘MUST’) to identify risk of malnutrition in older people living in the community

The underlying reasons for malnutrition (as undernutrition) in older people can result from medical (disease-related), physical and social factors that are often interlinked. With an ageing population, the majority of older people with or at risk of malnutrition are living in the community and still remain under-detected and under-treated by health and social care professionals (1). This is despite NICE guidance (2) and quality standards (3) recommending nutritional screening using validated tools such as the ‘Malnutrition Universal Screening Tool’ (‘MUST’).

Induced menopause: Why we need to make the most of NICE quality standards

Induced menopause: Why we need to make the most of NICE quality standards