Nurse-led Assessment Research Articles

Nurse led assessment of congestion in outpatient heart failure patients: remote dielectric sensing versus lung ultrasound comparison

Abstract Introduction Congestion stands as a primary driver behind exacerbating heart failure (HF), leading to hospitalizations and increased mortality rates. Despite the evident significance of congestion as a prognostic indicator, there exists a pressing need for a straightforward, trustworthy assessment method that caters to various healthcare providers' needs. Aims To assess the feasibility and compare the accuracy of nurse-led congestion assessment using radar based dielectric sensing (ReDS) to a "gold-standard" point of care assessment using lung ultrasound (LUS). Methods A retrospective analysis of consecutive patient visits at the ambulatory advanced HF clinic was used in which both exams (ReDS and LUS) were conducted. Study population included heart failure patients (Stage C, NYHA II-IV). ReDS, an objective non-invasive, transcutaneous measurement of lung fluid status, was assessed by HF nurse and LUS, evaluated using 6 measurement zones, was performed by HF cardiologist. Results During 17-month period and 174 clinic visits (103 patients), ReDS and LUS were recorded simultaneously. Mean ReDS reading was 33%±6% vs. mean LUS of 2.3±3.2 B-lines. Pearson correlation coefficient between the readings was moderate r= 0.41 (p<0.05). For LUS cutoff of 3 B-lines, ReDS sensitivity was 55.5% and specificity was 70% (p<0.01). ReDS negative predictive value (NPV) was 88% with positive predictive value (PPV) of 27%. ReDS overall accuracy was 68%. Conclusion Despite its low sensitivity, nurse-led ReDS assessment is feasible and possess a relatively high NPV allowing to rule out congestion at point-of-care. The simplicity of use empowers more health providers to assess congestion.

School Nurse-Led Health Assessment for Students Experiencing Homelessness: A Quality Improvement Project.

Childhood homelessness is increasing and is associated with negative health and academic outcomes. The goal of this quality improvement project was to improve access to healthcare and health outcomes for students experiencing homelessness through a school nurse-led comprehensive health assessment. The multilevel intervention included identifying students experiencing homelessness, conducting a standardized health assessment, and making referrals to care. This 8-month project was conducted in an urban school district. Feasibility and acceptability data were collected to guide sustainability. Student health and referral data were analyzed using descriptive statistics. At the project start, 688 students were identified as experiencing homelessness. More than half (67%) had a partial or fully completed health assessment during the project. Of the students assessed, most had a primary care provider, some had a health condition, and half had a dental home. Students experiencing homelessness would benefit from systematic school-based health assessments to identify unmet health needs.

A feasibility study of the CRISP intervention; a cardiovascular risk reduction intervention in patients with an abdominal aortic aneurysm.

Abdominal aortic aneurysm (AAA) screening/surveillance is implemented widely. Those in AAA-surveillance are at high-risk of cardiovascular-events. We developed an intervention, called CRISP, using intervention-mapping, to reduce cardiovascular-risk in AAA-surveillance. This study tested the CRISP intervention in routine clinical-care. The CRISP intervention, consisting of a nurse-led cardiovascular risk assessment and subsequent lifestyle change support using a self-care workbook and low-intensity nurse input was delivered in two screening/surveillance programmes. Those consenting to take part were followed-up with cardiovascular-assessments. Fidelity of intervention-delivery was assessed quantitatively/qualitatively. 40 men (mean age 75 ± 7 years) took part over four months and followed-up for a minimum six months. A sub-group of 25 patients and nine Health Care Professionals (HCPs) were interviewed. The median number of risk-factors that patients chose to focus on was two (range 0 to 4), with physical activity (n=17) being the most popular. Participants who had a 'red light' risk factor for stress, low mood, smoking or alcohol intake were offered a referral to appropriate services. Two were offered referral to mental-health services and took it up, three declined referrals to smoking or alcohol support services. The fidelity of intervention-delivery (a score intervention components delivered to each patient based on a score from 0 to 5, with 5 being highest delivery fidelity) was generally low. The highest mean score (on a 0-5 scale) for the nurse assessment was 1.5 for engaging the participant, lowest 0.5 for exploring the importance for selected lifestyle behaviours. In qualitative interviews, the intervention was liked by patients/HCPs. Based on qualitative interviews and observations, the low fidelity of intervention-delivery was due to intervention-training not being detailed. CRISP can be delivered in AAA-surveillance, but fidelity of delivery is low. The intervention and its training need to be refined/tested before wider implementation. ISRCTN9399399518/11/20).

Understanding hepatitis C virus (HCV) health literacy and educational needs among people in prison to enhance HCV care in prisons

BackgroundHepatitis C virus (HCV) is a significant concern within prison populations. Provision of HCV testing and treatment for people in prison is expanding and a key component of global elimination efforts. Despite growing service availability, several challenges remain in HCV testing and treatment engagement during incarceration. The PIVOT study demonstrated that a ‘one-stop-shop’ intervention (point-of-care HCV RNA testing, Fibroscan®, nurse-led clinical assessment, and fast-tracked direct-acting antiviral prescription) enhanced HCV testing and treatment at a reception prison in Australia. Utilising Squier et al's Health Literacy Skills Framework, this analysis aimed to understand HCV health literacy and educational needs among people at a reception prison in Australia. MethodsSemi-structured interviews were conducted with twenty-four male PIVOT study participants. Purposive sampling ensured comparable representation of those with: 1) prior HCV testing history (standard pathology / no prior testing), and 2) injecting drug use history (IDU; ever / never). ResultsVaried HCV health literacy levels and educational needs were evident amongst people in prison. Whilst those with multiple incarceration episodes and IDU history (prior knowledge) appeared to have stronger HCV health literacy than those without, substantial gaps in HCV health literacy were evident. Knowledge of HCV transmission risks in prison was high, and most understood the importance of HCV testing and treatment in prison (comprehension), but ability to engage with HCV testing and treatment services, participation in safe injecting behaviours (health-related behaviours), and knowledge of re-infection and re-treatment, within the context of the prison environment, were suboptimal. There was a general desire for increased HCV education in prison. ConclusionGaps in HCV health literacy among people in prison were evident, indicating opportunities for improvement. A targeted HCV education program for people in prison, addressing the gaps identified in this analysis, may enhance HCV testing, treatment, and prevention by fostering stronger HCV health literacy among people in prison.

A feasibility study of the CRISP intervention; a cardiovascular risk reduction intervention in patients with an abdominal aortic aneurysm

Background Abdominal aortic aneurysm (AAA) screening/surveillance is implemented widely. Those in AAA-surveillance are at high-risk of cardiovascular-events. We developed an intervention, called CRISP, using intervention-mapping with patients and stakeholders, to reduce cardiovascular-risk in AAA-surveillance. This study tested the CRISP intervention in routine clinical-care. Methods The CRISP intervention, consisting of a nurse-led cardiovascular risk assessment and subsequent lifestyle change support using a self-care workbook and low-intensity nurse input was delivered across Leicestershire and Rutland AAA screening/surveillance programmes. Those who consented to take part were followed-up with cardiovascular-assessments. Fidelity of intervention-delivery was assessed quantitatively and qualitatively. Results 40 men (mean age 75 + 7 years) took part over four months and were followed-up for a minimum six months. A sub-group of 25 patients and nine Health Care Professionals (HCPs) were interviewed. The median number of risk-factors that patients chose to focus on was two (range 0 to 4), with physical activity (n=17) being the most popular. Participants who had a ‘red light’ risk factor for stress, low mood, smoking or alcohol intake were offered a referral to appropriate services. Two were offered referral to mental-health services and took it up, three declined referrals to smoking or alcohol support services. The fidelity of intervention-delivery was generally low. The highest mean score (on a 0-5 scale) for the nurse assessment was 1.5 for engaging the participant, lowest 0.5 for exploring the importance for selected lifestyle behaviours. In qualitative interviews, the intervention was liked and viewed as beneficial by patients and HCPs. Based on qualitative interviews and observations, the low fidelity of intervention-delivery was due to intervention-training not being detailed. Conclusions The CRISP intervention can be delivered in AAA-surveillance, but the fidelity of delivery is low. The intervention and its training course need to be refined and tested before wider implementation. Registration ISRCTN (ISRCTN93993995; 18/11/2020).

Collaborative implementation of an evidence-based package of integrated primary mental healthcare using quality improvement within a learning health systems approach: Lessons from the Mental health INTegration programme in South Africa.

The treatment gap for mental health disorders persists in low- and middle-income countries despite overwhelming evidence of the efficacy of task-sharing mental health interventions. Key barriers in the uptake of these innovations include the absence of policy to support implementation and diverting of staff from usual routines in health systems that are already overstretched. South Africa enjoys a conducive policy environment; however, strategies for operationalizing the policy ideals are lacking. This paper describes the Mental health INTegration Programme (MhINT), which adopted a health system strengthening approach to embed an evidence-based task-sharing care package for depression to integrate mental health care into chronic care at primary health care (PHC). The MhINT care package consisting of psycho-education talks, nurse-led mental health assessment, and a structured psychosocial counselling intervention provided by lay counsellors was implemented in Amajuba district in KwaZulu-Natal over a 2-year period. A learning health systems approach was adopted, using continuous quality improvement (CQI) strategies to facilitate embedding of the intervention.MhINT was implemented along five phases: the project phase wherein teams to drive implementation were formed; the diagnostic phase where routinely collected data were used to identify system barriers to integrated mental health care; the intervention phase consisting of capacity building and using Plan-Do-Study-Act cycles to address implementation barriers and the impact and sustaining improvement phases entailed assessing the impact of the program and initiation of system-level interventions to sustain and institutionalize successful change ideas. Integrated planning and monitoring were enabled by including key mental health service indicators in weekly meetings designed to track the performance of noncommunicable diseases and human immunovirus clinical programmes. Lack of standardization in mental health screening prompted the validation of a mental health screening tool and testing feasibility of its use in centralized screening stations. A culture of collaborative problem-solving was promoted through CQI data-driven learning sessions. The province-level screening rate increased by 10%, whilst the district screening rate increased by 7% and new patients initiated to mental health treatment increased by 16%. The CQI approach holds promise in facilitating the attainment of integrated mental health care in resource-scarce contexts. A collaborative relationship between researchers and health system stakeholders is an important strategy for facilitating the uptake of evidence-based innovations. However, the lack of interventions to address healthcare workers' own mental health poses a threat to integrated mental health care at PHC.

Evaluation of a nurse-led glaucoma assessment clinic for non-complex patients.

The purpose of this study was to assess the safety, feasibility and effectiveness of a nurse-led glaucoma assessment clinic service. Glaucoma is a group of serious, irreversible optic neuropathies that progressively damage the optic nerve resulting in blindness. Over 64.3 million people globally are affected by glaucoma with numbers projected to increase to 111.8 million by 2040. Glaucoma is a major public health concern that requires the development of innovative models of care to meet current and future health care demands. A mixed method design was used to evaluate the assessment of non-complex glaucoma patients attending a new nurse-led clinic. Under an ophthalmologist's supervision, the glaucoma nurse completed 100 hof clinical training and assessment to ensure they were competent in completing and interpreting the required glaucoma assessment protocols. Interrater reliability between the glaucoma nurse and ophthalmology doctor was undertaken. Glaucoma patient waitlist appointment data were also compared before and after the introduction of the nurse-led clinics. This study adhered to the SQUIRE checklist for the reporting of excellence with quality improvement projects. Patients contributed to the evaluation of this new nurse-led service by providing follow-up feedback on their experience. Agreement between clinicians for appropriate follow-up appointment times was high with 93% (n= 315) agreement achieved. Furthermore in 297 (87.5%) cases, both clinicians agreed on the patient being referred to the doctor for follow-up review. Glaucoma consultations were shown to increase from 3,115 appointments in 2019/20 to 3,504 appointments in 2020/21 after the introduction of the nurse-led clinic. The nurse-led clinics accounted for 14.5% (n= 512) of clinic appointments. The introduction of the nurse-led glaucoma assessment clinic service allowed patients to be reviewed safely, efficiently and satisfactorily. This new service subsequently allowed for more complex glaucoma patients to be seen bythe ophthalmologists. Findings revealed that suitably trained glaucoma nurses are able to clinically assess and safely monitor stable non-complex glaucoma patients. Highlights the need for appropriate investment in clinical training and supervision to ensure that glaucoma assessment nurses are adequately prepared to undertake this new practice role.

Diagnostic accuracy of the "4 A's Test" delirium screening tool for the postoperative cardiac surgery ward.

Delirium is prevalent and underdetected among cardiac surgery patients on the postoperative ward. This study aimed to validate the 4 A's Test delirium screening tool and evaluate its accuracy both when used by research assistants and when subsequently implemented by nursing staff on the ward. This single-center, prospective observational study evaluated the performance of the 4 A's Test administered by research assistants (phase 1) and nursing staff (phase 2). Assessments were undertaken during the patients' first 3 postoperative days on the postcardiac surgery ward along with previous routine nurse-led Confusion Assessment Method assessments. These index tests were compared with a reference standard diagnosis of delirium based on Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria. Surveys regarding delirium screening were administered to nurses pre- and postimplementation of the 4 A's Test in phase 2 of the study. In phase 1, a total of 137 patients were enrolled, of whom 24.8% experienced delirium on the postoperative cardiac ward. The 4 A's Test had a sensitivity of 85% (95% confidence interval, 73-93) and a specificity of 90% (95% confidence interval, 85-93) compared with the reference standard. The nurse-assessed Confusion Assessment Method had a sensitivity of 23% (95% confidence interval, 13-37) and specificity of 100% (95% confidence interval, 99-100). In phase 2, nurses (n=51) screened 179 patients for delirium using the 4 A's Test. Compared with the reference rater, the 4 A's Test had a sensitivity of 58% (95% confidence interval, 28-85) and specificity of 94% (95% confidence interval, 85-98). Postimplementation, 64% of nurses thought that the 4 A's Test improved their confidence in delirium detection, and 76% of nurses would consider routine 4 A's Test use. The 4 A's Test demonstrated moderate sensitivity and high specificity to detect delirium in a real-world setting after cardiac surgery on the postoperative ward. A modified model of use with less frequent administration, along with increased engagement of the postoperative team, is recommended to improve early delirium detection on the cardiac surgery postoperative ward.

BS P02 Sleeve gastrectomy and gastric bypass day surgery: outcomes and experience from a single centre

Abstract Background Internationally, day case Bariatric surgery has been shown to be safe, feasible and economically beneficial. However, it has not been widely adopted in the UK. It requires careful patient selection and a mature enhanced recovery programme. We report on the outcomes and lessons learned during our 2.5-year experience of day case laparoscopic sleeve gastrectomies (LSG) and Roux-en-y gastric bypass (RYGB) operations. Methods A retrospective analysis was performed of all patients who were selected as candidates for day case Bariatric surgery in a single-centre since October 2019. Patients were considered eligible if they had a BMI <60, lived within 30 minutes of the hospital, were having primary surgery with no additional procedure and were not on CPAP. All patients received a nurse-led telephone assessment on day 1. Rates of successful discharge, patient demographics, readmission and outcomes were analysed. Results Thirty-nine patients were identified as suitable candidates for day case operations: 24 (62%) RYGB, 15 (38%) LSG. The mean BMI was 46.5; 85% female. The main reason for not being considered was the patient living >30 minutes away. Overall, 18 (13 RYGB, 5 LSG; 46.2%) were successfully discharged on the day of surgery. Fifteen (38.5%) were discharged on the first post-operative day and 6 (15.4%) stayed two or more days. The commonest reasons for failed discharge were nausea/vomiting 6 (15.4%) and logistical issues e.g. operation in the afternoon 6 (15.4%). There was one readmission within 30 days (sealed leak from the gastro-jejunal anastomosis) but no returns to theatre. Conclusions We have successfully performed day case Bariatric surgery in our centre. However, it is a logistical challenge and to date has only been carried out successfully on a small number of patients. The main challenge being the vast catchment area for our tertiary centre. Further work is needed to better define the parameters for patient eligibility in order to safely offer this to more patients.

S54 Improving Influenza and Pneumococcal Vaccination Rates in an Inflammatory Bowel Disease Clinic at Tan Tock Seng Hospital, Singapore

Background: Despite a higher risk of infections (such as influenza and pneumococcal disease) with or without immunosuppressive or biologic therapies, vaccination rates remain low among inflammatory bowel disease (IBD) patients in Tan Tock Seng Hospital. Specifically, our 3 months’ retrospective data revealed that ≤15% of patients had completed their influenza and pneumococcal vaccinations. Hence, in January 2021, a team comprising of 3 IBD physicians and 2 new IBD nurses came together to work on a quality improvement (QI) project and streamline the vaccination processes. The primary aim was to improve vaccination rates through a nurse-led vaccination screening, assessment and referral exercise as well as addressing vaccination hesitancy. Methods: A cause and effect QI tool (fish-bone diagram) was adopted to assess and study areas for improvement. Through this root cause analysis, the team was able to identify gaps which contributed to poor vaccination uptake. They included system (unavailability of IBD vaccination protocol, no written education materials for IBD patients, inconvenient vaccination access), physician (limited physician time consult, incomplete vaccination screening or assessment) and patient factors (patient’s perceived lack of benefit, vaccine misconceptions, fear of side effects). In order to address aforementioned factors causing the poor vaccination rates, vaccination guidelines were first protocolised based on national and international clinical guidelines. An information pamphlet was also prepared to help patients better understand the importance and benefits of vaccinations. At each outpatient appointment, IBD nurses would first establish the patient’s vaccination eligibility based on age, disease activity, use of immunosuppressive therapy and vaccination history. Where appropriate, vaccination counselling and pamphlet will be provided to the patient. With patient’s consent, patients would then be referred to the treatment room at the clinic for vaccination administration, all within the same clinical setting. Results: There were 246 patients attended IBD clinic from June to November 2021. Our 6-months post-intervention study reported the following: 1. Clear and systematic vaccination screening and assessment- Vaccination documentation in electronic health records increased from 30% to 100% - a 70% increase compared to pre-intervention 2. Influenza vaccination- 60% of IBD patients fulfilled vaccination eligibility - Influenza vaccination completion increased from 13% to 55% – a 42% increase compared to pre-intervention 3. Pneumococcal vaccination- 28% of IBD patients fulfilled vaccination eligibility - Pneumococcal vaccination completion increased from 2% to 48% - a 46% increase compared to pre-intervention. Conclusion(s): The role of vaccination screening and recommendations were traditionally performed by physicians and pharmacists. However, with the implementation of nurse-led vaccination exercise, it had helped to improve and better identify eligible patients for vaccination in a systematic and concise manner in this one-stop service. It further empowered the 2 new IBD nurses in exercising their clinical judgement skills while freeing up time for physicians to address patients who may have higher medical needs requiring longer consultations. Most importantly, with increasing vaccination rates, IBD patients could be better protected against these vaccines-preventable diseases. We believe that we can achieve higher rates of vaccinations in due time through education and being a vaccine(s) advocate to further reduce vaccine hesitancy.

OA08.06 Implementation of a Nurse-led Geriatric Oncology Assessment Model in the Lung Cancer Care Pathway

The incidence of lung cancer increases with age. The comprehensive geriatric assessment (CGA) identifies patients at high risk of adverse outcomes and has shown to improve health-related outcomes, quality of life and reduction in health service use. However, the uptake is hampered by limitations in both time and resources. We evaluated the implementation of a nurse-led model of geriatric oncology assessment for elderly patients (≥ 65 years) with newly diagnosed lung cancer.

The utilization of a nurse-led clinic by older people with cognitive complaints: Do they follow our advice?

Cognitive assessment services were found to be beneficial to older people with cognitive complaints but information is limited on adherence to the recommendations provided. This study aimed to identify predictors of clients' adherence to nursing recommendations after attending a community-based nurse-led cognitive assessment service in Hong Kong. A cross-sectional design was adopted. We analysed a dataset routinely collected from clients attending the services between January 2012 and January 2018. Multiple regression analyses were conducted to identify predictors (demographics, functional health status and cognitive performance) of the clients' adherence. Their satisfaction with the services was also examined. Two hundred and twenty-three clients attended the clinic. Of the 133 who completed the telephone follow-up at the 6months postconsultation, 44.1% did not adhere to the recommendations. Clients with a higher Clinical Dementia Rating (OR = 4.17), lower Clock Drawing Test score (OR = 1.13) and lower education level (OR = 0.91) were found to be less likely to adhere to the nursing recommendations. Ninety-six percent (190/198) were satisfied with the overall services. Cognitive assessment services in nurse-led clinics could provide a self-referred service for older people with cognitive complaints. However, low adherence to nursing recommendations was found among clients with poorer cognitive functions and lower education levels.

OS079 - Nurse-led inpatient fibrosis assessment for patients with suspected alcohol related liver disease and previous poor engagement with services

OS079 - Nurse-led inpatient fibrosis assessment for patients with suspected alcohol related liver disease and previous poor engagement with services

964 MOUTHCARE MATTERS: QI PROJECT TO IMPROVE ORAL HEALTH IN ELDERLY HOSPITAL INPATIENTS

Abstract Background A quality improvement (QI) project completed over four months on an elderly-care ward comprising 34 inpatients in a UK district general hospital. The QI team comprised the ward Foundation Year 1 (FY1) and Consultant, with Nursing staff consultation. Introduction There is evidence that oral-health in elderly people deteriorates with hospitalisation (Terezakis et al. J Clin Periodontol. 2011;38(7):628–636). Poor oral-health is associated with increased incidence of hospital-acquired infections and reduced oral intake (Kaneoka et al. Infect Control Hosp Epidemiol. 2015;36(8):899–906; Poisson et al. Gerodontology. 2016;33(2):61–168). We had no data on oral-health among our hospital inpatients, nor on nursing measures to maintain or improve it. We aimed to collect baseline data and implement ward-based improvements to oral-health assessment and care. Method Interventions were identified using a ‘drivers-for-change’ flow-diagram: main interventions were introduction of a mouthcare proforma (for nurse-led assessment of patient oral-health and documentation of mouthcare given), ensuring availability of mouthcare products and providing relevant ward-staff education. Two ‘Plan-Do-Study-Act’ cycles were completed; intervention implementation was staggered two-monthly, following evaluation of preceding changes’ impact. Data to measure impact of changes was collected two-monthly by the FY1 on patient oral-health (subjectively scored with assessment tool), rate of proforma completion and patient-reported completion of routine mouthcare. Results Over the four-month period, there were significant improvements to rates of oral-health assessment (proforma completion increased by 86%), completion of routine mouthcare (increased by 32%), and overall patient oral-health: proportion of ‘good’ or ‘excellent’ oral-health scores increased from 21% to 66%. We aim to deliver further ward-based education to maintain progress. Conclusion These interventions are simple, low-cost and could be implemented across many elderly-care wards. Wider adoption would improve mouthcare across larger patient-numbers, with potential benefit to both patient experience and morbidity. Ongoing education and integration of the proforma into existing ward ‘patient-care-bundles’ will promote sustained improvement.

Preliminary findings of implementing the G8 screening tool in an academic cancer center.

12010 Background: Older patients often experience more toxicity from cancer treatments due to their functional age and co-morbidities. The G8 is a geriatric screening tool designed to identify patients who are appropriate for a comprehensive geriatric assessment (CGA) which will inform and optimize oncology therapeutic decision making, reduce toxicities and improve outcomes. Using a nurse-led assessment approach, we have implemented an EMR embedded G8 tool across our cancer center since June 2020. We aim to describe the characteristics of those patients who scored abnormal (≤ 14) on the G8. Methods: The demographic and clinical characteristics were collected from the EMR for those who were ≥ 65 and have completed the G8 screening tool from June 2020 to Jan 2022. Summary statistics such as means, standard deviations and proportions were reported. Comparisons of various endpoints between dichotomized (≤ 14 vs. > 14) G8 scores were performed using pairwise two-sample t-test, pairwise proportion test, Fisher’s exact test and/or Pearson’s chi-squared test. Selected stakeholders were elicited for their perspectives on the implementation process. Results: 544 patients age ≥ 65 completed G8 screening with a mean score of 13.4 (± 2.3). The mean age was 75.2 (± 7.0), and 55.7% were females and 78.3% were non-Hispanic White. The most frequent cancer type was breast cancer (21.3%), followed by lung/respiratory cancer (18.2%), and GI cancer (15.8%). The percentage of patients appropriate for a CGA (based on an abnormal G8 score) was 59% (n = 332), of which only 10% (n = 31) were referred. A spearman correlation of 0.4 (p < 0.001) between G8 scores and age was obtained. A statistically significant association between ECOG and G8 groups was found, but not for any comorbidities. The prevalence of current/former smoking and extreme polypharmacy (> 10) is significantly higher in the G8 abnormal group. Implementation process evaluation found new patients with cancer overwhelmed with information, a lack of patient education and provider engagement, and an unstandardized referral process to CGA, were barriers for CGA referral. Conclusions: The G8 is an effective tool identifying patients appropriate for a CGA. An EMR embedded G8 steadily improved the G8 utilization uptake but not referral for CGA at our institution. To further improve awareness, utilization and referral, we are redesigning a hybrid workflow integrating patient-mediated MyChart implementation and nurse navigator engagement. EPIC enhancements are being designed to inform the oncologist of the patient’s G8 score, CGA referral status and the final CGA report.

Nurse-led cardiovascular diseases risk assessment and communication using WHO/ISH risk prediction chart in a tertiary care hospital of North India.

Cardiovascular diseases (CVDs) contribute to most of the potentially preventable burden through early risk assessment. Nurse-led CVD risk assessment is an effective strategy to address the human resource crisis for CVD prevention. An interventional study was conducted in medicine wards of a tertiary care hospital in North India to train nurses in CVD risk assessment and its communication. All bedside nurses (n = 30) of selected wards were enrolled and trained in CVD risk assessment and communication using WHO/ISH risk prediction charts. Once fully trained, each nurse enrolled patients (>40 years of age) from their respective wards to assess and communicate CVD risk. To calculate the reliability of risk assessment, investigator simultaneously assessed CVD risk with nurses. The mean age of nurses was 32.07 ± 6.31 years. The results revealed that training significantly increased the knowledge of nursing personnel (P < 0.001). There was perfect inter-rater reliability agreement (Cohen's k = 0.929) between nurses and investigators while assessing CVD risk. Nurses demonstrated good communication skills. The study concluded that nurses can be trained successfully in CVD risk assessment and communication. The study recommends the task shifting of CVD risk assessment to nurses after providing proper training.

Sexual and reproductive health needs assessment and interventions in a female psychiatric intensive care unit.

To assess the sexual and reproductive health (SRH) needs of women admitted to a psychiatric intensive care unit (PICU), and acceptability of delivering specialist SRH assessments and interventions in this setting. Within a quality improvement framework, staff were trained, a clinical protocol developed and clinical interventions made accessible. Thirty per cent of women were identified as having unmet SRH needs and proceeded to a specialist appointment, representing a 2.5-fold increase in unmet need detection. Forty-two per cent of women were assessed, representing a 3.5-fold increase in uptake. Twenty-one per cent of women initiated SRH interventions, of which 14% had all their SRH needs met. Staff, patients and carers highlighted the acceptability and importance of SRH care, if interventions were appropriately timed and patients' individual risk profiles were considered. Barriers to access included lack of routine enquiry, illness acuity and impact of the COVID-19 pandemic. SRH needs for PICU admissions are greater than previously realised. Providing a nurse-led SRH assessment is acceptable, feasible and beneficial for PICU patients.

A telephonic cardiology advice line was effective during the COVID-19 pandemic in both reassuring patients and in ensuring patients received optimal urgent care

A decrease in patients accessing health care was documented during the first COVID-19 surge.We established a 24/7 cardiology telephone advice service during the first surge, this was provided by an experienced cardiology nurse based in a nurse-led cardiac assessment unit. Various options were available on the basis of the telephone consultation. We particularly wanted to see the outcomes of reassurance of patients (to see if the approach was safe) and the outcomes of patients who were directed to emergency departments (to see if this identified patients with significant cardiological and medical problems who may not otherwise have accessed healthcare).We reviewed the progress of the first 999 patients who used the telephonic service for which we had 90 day follow-up data.141 patients were initially reassured by the nurse at the telephone call. Of these, 55 patients had no further engagement with healthcare providers in the subsequent 90 days. 7 were followed-up within the cardiac rehabilitation program that they were already participating in. 21 were referred to cardiology by their GP but all subsequently had normal assessment and/or investigation. 30 attended an emergency department of whom 22 were discharged directly from the ED; the other 8 patients were admitted to hospital which included 2 patients with non-cardiac chest pain and 2 with exacerbations of known heart failure. 28 patients recontacted the telephonic service during the 90 days and had subsequent face-to-face assessment. There was one death amongst the 141 patients, from a known malignancy.161 patients were advised to attend an emergency department following telephonic evaluation of whom 50 did not attend. 84 patients were discharged home following assessment in the emergency department of whom 18 were discussed or referred to cardiology for outpatient assessment. 20 patients were admitted under cardiology (8 non-STEMI, 1 complete heart block, 1 profound bradycardia, 1 atrial fibrillation, 1 congestive cardiac failure, 1 critical aortic stenosis, 1 chemotherapy associated cardiotoxicity, 4 no significant cardiac issue found). Nine patients were admitted to non-cardiac wards.We believe that nurse-led telephonic triage can be effective in the management of patients in the community with established cardiac disease or with potential cardiac symptoms. We intend to further develop the service we established during the first surge of the COIVD-19 pandemic.FUNDunding AcknowledgementType of funding sources: None.

How a pandemic changed advanced nurse practitioner (ANP) chest pain assessment from face-to-face to virtual: The impact on clinical workload, diagnosis &amp; patient safety

Abstract Funding Acknowledgements Type of funding sources: None. Chest pain presentations to the Emergency Dept. (ED) account for 8% of ED cases annually. In response to the pandemic the usual care pathway of nurse-led assessment in ED and discharge to a chest pain clinic (Ingram 2017) ceased, as face-to-face clinics and diagnostics were curtailed, and staff redeployed. A virtual chest pain clinic was created by one ANP. Telehealth is defined as ‘the entire spectrum of activities used to deliver care remotely, without direct physical contact with the patient’ (Wosik 2020) Purpose This analysis aims to compare the outcomes of the Covid-19 virtual chest pain clinic in 2020 to the same face-to- face clinic period in 2019 with a focus on i. Clinic workload, ii. Patient Outcomes iii. Patient Safety, Methods The ANP performed a telephone consultation and referred for limited diagnostic testing or discharged to primary care. The patient management system (iPIMS) was used as a clinical and audit tool. This service evaluation was registered as quality improvement project. Results From 1/4/20 to 21/7/2020, 130 e-referrals were received compared to 154 face-to-face consults in the same period of 2019. The overall number of clinic episodes was 17% greater during the pandemic period (Fig.1), carried out by 1/3 of the 2019 staff quota. Access to exercise stress testing (EST) was reduced by 88%. CHD was diagnosed in 26%. Virtual assessment in this high risk group in the absence of timely diagnostics is a risk however 30 day mortality was 0%. Discussion The pandemic of covid-19 required a rapid redesign of the chest pain service in the midst of staff redeployment. Whilst the total number of referrals is less that the same timeframe in 2019 the ‘virtual’ nature of the service created additional episodes of care with the need for the return clinic in person or by telephone. Conclusion In response to the pandemic the change to a virtual clinic was enabled by ANP experience and permitted continued safe discharge of chest pain patients from the ED. The virtual service does add to the ANP clinical workload with potential risk. As it requires more office time, it prevents the ANP presence in the ED. It is hoped in time to return to the original model of care as this will be more efficient for the service and the patient.

Efficacy of Reduced-Intensity Chemotherapy With Oxaliplatin and Capecitabine on Quality of Life and Cancer Control Among Older and Frail Patients With Advanced Gastroesophageal Cancer

Older and/or frail patients are underrepresented in landmark cancer trials. Tailored research is needed to address this evidence gap. The GO2 randomized clinical trial sought to optimize chemotherapy dosing in older and/or frail patients with advanced gastroesophageal cancer, and explored baseline geriatric assessment (GA) as a tool for treatment decision-making. This multicenter, noninferiority, open-label randomized trial took place at oncology clinics in the United Kingdom with nurse-led geriatric health assessment. Patients were recruited for whom full-dose combination chemotherapy was considered unsuitable because of advanced age and/or frailty. There were 2 randomizations that were performed: CHEMO-INTENSITY compared oxaliplatin/capecitabine at Level A (oxaliplatin 130 mg/m2 on day 1, capecitabine 625 mg/m2 twice daily on days 1-21, on a 21-day cycle), Level B (doses 0.8 times A), or Level C (doses 0.6 times A). Alternatively, if the patient and clinician agreed the indication for chemotherapy was uncertain, the patient could instead enter CHEMO-BSC, comparing Level C vs best supportive care. First, broad noninferiority of the lower doses vs reference (Level A) was assessed using a permissive boundary of 34 days reduction in progression-free survival (PFS) (hazard ratio, HR = 1.34), selected as acceptable by a forum of patients and clinicians. Then, the patient experience was compared using Overall Treatment Utility (OTU), which combines efficacy, toxic effects, quality of life, and patient value/acceptability. For CHEMO-BSC, the main outcome measure was overall survival. A total of 514 patients entered CHEMO-INTENSITY, of whom 385 (75%) were men and 299 (58%) were severely frail, with median age 76 years. Noninferior PFS was confirmed for Levels B vs A (HR = 1.09 [95% CI, 0.89-1.32]) and C vs A (HR = 1.10 [95% CI, 0.90-1.33]). Level C produced less toxic effects and better OTU than A or B. No subgroup benefited from higher doses: Level C produced better OTU even in younger or less frail patients. A total of 45 patients entered the CHEMO-BSC randomization: overall survival was nonsignificantly longer with chemotherapy: median 6.1 vs 3.0 months (HR = 0.69 [95% CI, 0.32-1.48], P = .34). In multivariate analysis in 522 patients with all variables available, baseline frailty, quality of life, and neutrophil to lymphocyte ratio were independently associated with OTU, and can be combined in a model to estimate the probability of different outcomes. This phase 3 randomized clinical trial found that reduced-intensity chemotherapy provided a better patient experience without significantly compromising cancer control and should be considered for older and/or frail patients. Baseline geriatric assessment can help predict the utility of chemotherapy but did not identify a group benefiting from higher-dose treatment. isrctn.org Identifier: ISRCTN44687907.