Retrospective Case Note Audit Research Articles

Borderline personality disorder and parenting capacity: Understanding child protection population characteristics

Objective This paper describes an audit of borderline symptoms, risk factors for maltreatment and types of abuse among parents who completed a parenting capacity assessment at a South Australian health-based child protection service. Method A retrospective case note audit within a 28-month period was conducted and included parents ( n = 107) who had completed a Mclean’s screening instrument for borderline personality disorder and/or had a psychiatric review with a formal diagnosis. Parents who had a borderline personality disorder diagnosis or endorsed five or more symptoms were categorised into the ‘high’ borderline symptom group. Rates of parental risk factors for maltreatment and type of abuse were compared between parents with low or high borderline symptoms. Results Forty percent of parents endorsed at least five borderline symptoms on the screening tool. On average, parents high in borderline symptoms had a greater number of parental risk factors. Conclusions These findings highlight the importance of screening for personality pathology among parents presenting to child protection services. Foundational training for staff and making evidence-based interventions available should be considered in such settings.

Suppression head impulse test in children-experiences in a tertiary paediatric vestibular centre.

The suppression head impulse paradigm (SHIMP) involves suppression of the vestibulo-ocular reflex (VOR) and anticompensatory saccades generated thereof. SHIMP is gaining importance to understand vestibular compensation with its different parameters (VOR gain/peak saccadic velocity PSV/latency of saccades). SHIMP studies are emerging in adults, but pediatric studies have hardly been performed. This study is a retrospective case note audit over a period of 2 months in a tertiary pediatric vestibular center in the United Kingdom to investigate whether SHIMP is safe/robust to be used in children conforming to existing standards/norms in normal children and whether it yields any meaningful inferences in pediatric vestibular hypofunction. This is the largest pediatric SHIMP study to date. A total of 44 referred children (6-18 years, female children>male children) with a range of complaints from dizziness, imbalance, motor incoordination, postural instability, and hearing loss were included, and their SHIMP parameters were measured. All children underwent comprehensive functional/objective audiovestibular assessments. Two groups were defined-Group A with normal vestibular function and Group B with abnormal vestibular function. The normal population showed an average SHIMP VOR gain of 0.98+/-0.08 and latency of overt saccades at 215.68+/-46.16 milliseconds agreeing with published evidence. The PSV of overt saccades was 315.39+/-56.30/s, and there was a gain asymmetry of 7.42+/-4.68 between the sides. Statistically significant differences with moderate/large effect sizes were observed between the groups in terms of VOR gain and PSV but not in saccade latencies. Covert saccades were rare in SHIMP, while overt saccades were observed in 100% of children. VOR gain difference between the head impulse paradigm (HIMP) and the SHIMP was significant as well. We observed statistically significant differences in side asymmetry of VOR gain between the groups. Furthermore, we identified a group of children with cerebellar lesions where overt saccades in SHIMP were rather low in number. Further research is recommended to investigate pediatric PSV, asymmetry, and inability to generate overt saccades that may suggest useful means to assess compensation and central function. We conclude that SHIMP yields valuable information and is a safe, easy to perform, and a reliable test that should be used in children to supplement HIMP.

Interpretation services used for non-English language speaking patients with head and neck cancer: Findings from a tertiary London cancer centre

BackgroundTreatment for head and neck cancer (HNC) can lead to profound changes in swallowing function and nutrition. UK HNC standards recommend informational counselling is provided pre-treatment by the dietitian and speech and language therapist (SLT). Non-english speaking patients treated in English speaking countries have poorer treatment outcomes. UK guidance recommends all patients should have access to interpretation services where required. This audit aimed to investigate the language needs and utilisation of interpretation services for patients with HNC attending pre-treatment clinics. MethodsA retrospective casenote audit over two-years (2021–2023) of all patients attending pre-treatment clinics in a centralised London cancer centre. Information was collected from electronic hospital records on demographics, disease/treatment characteristics, first language; categorised as English primary language (EPL), non-English primary language (NEPL) and interpretation requirements; formal (professional interpreters) or informal (patients friends/relatives). Data was processed and collated using Microsoft Excel (Version 2308). Descriptive statistics were conducted using Excel Analysis ToolPak. Results408 patients were included. Most patients were male (67%), aged 61 ± 13 years. 18% (n = 74) had NEPL; 58 required interpretation services. Formal interpretation service was provided in 43% (n = 25), informal services in 33% (n = 19), and no service in 24% (n = 14). Non-adherence to formal services included lack of/inaccurate documentation of language needs, patient preference and lack of available interpreters. ConclusionThis audit indicated that barriers exist in utilising formal interpretation services. Future research should investigate how this can be optimised to ensure necessary language support is provided consistent with guidelines that promote equality, diversity, and inclusion.

Improving the quality of antenatal screening and early intervention for alcohol and other drug use: protocol for a multi-stage approach to systems reform

BackgroundAlcohol, tobacco and illicit drug use during pregnancy can cause significant harm to women and their developing fetuses. Despite recommendations for abstinence during pregnancy, some women continue to use, making screening for substance use during antenatal clinic attendances an important strategy for reducing risk. This study aims to improve the rates of screening and intervention for substance use among pregnant women, including appropriate referral for those who may be substance-dependent. The protocol outlined here focuses on a multi-stage implementation study.MethodsThis study will occur in four phases. Phase 1 will identify a baseline rate of screening and subsequent care at the antenatal clinics of two, South Australian hospital-based maternity services, through a retrospective case note audit. Rates of self-reported substance use identified in the case notes will also be compared against representative data from Adelaide Primary Health Network to establish rates of over or underreporting. Phase 2 will involve an online Training Needs Analysis of midwifery staff working at those services, to assess their knowledge, attitudes, beliefs, and commitment to the care of women who use substances during pregnancy. Phase 3 will involve a training package for all midwifery staff at those services, focused on routine screening for substance use, and how to provide appropriate care. Outcome measures from phase 2 will be reassessed during phase 3 and any changes since training will be evaluated. Phase 4 will then repeat phase 1 to compare the changes in rates of both screening and any associated intervention before and after training.DiscussionFrom a public health perspective, this project has the potential to make a significant impact on reducing risk of harm from substance use disorders among pregnant women, and contribute to better health outcomes for their children.Trial registration: This trial has been pre-registered under the Open Science Framework. Registration: https://doi.org/10.17605/OSF.IO/73FDZ.

The Efficacy of Same Day Plerixafor Dosing on CD34+ Haematopoietic Stem Cell Collection: A Single Centre Australian Experience

Introduction: Haematopoietic stem cell (HSC) transplantation is an important therapeutic option for many haematological conditions, as well as, some solid organ cancers. Plerixafor (a selective inhibitor of CXCR4) can be used in patients for primary stem cell mobilisation; those who have previously failed stem cell mobilisation ("rescue" or "Planned"); or in patients with a poor peripheral CD34+ response to GCSF and/or chemotherapy mobilisation ("on demand", "just in time" or "pre-emptive"). In Australia, Plerixafor is funded for patients with CD34+ count <10 cells/µl on day of collection or if first apheresis has yielded CD34+ <1 x 106cells/kg. In these patients, Plerixafor is administered the evening prior to the planned morning collection but this presents logistical issues as it has to be given after hours. Therefore, it was proposed to administer Plerixafor followed by same day HSC collection to improve the logistics of these "just in time" collections. Methods: A retrospective case note audit identified 96 patients who received Plerixafor for HSC collection between 03/2017 and 06/2021. Patients were categorised into PM (late afternoon/evening dosing) and AM (morning dosing). Transplant HSC dose target was >2 x 106/kg. Results: Of the 96 patients, 17 received 2 doses of plerixafor with 4 of these patients receiving both an AM and PM dose. These 4 patients were excluded from the final analysis. Of the 92 patients remaining, 57% (n=52) of patients received PM and 43% (n=40) AM dosing. Median age was 64 years (range 23 to 78). 58% were male (n=53) and 42% female (n=39). Underlying malignancy included Myeloma (n=51), Lymphoma (n=37) and Solid malignancy (n=4). Median pre plerixafor blood CD34+ count was 8.7x10^6/kg (range 0.3-35.5) in the PM group and 9.2 (range 1.6-38.2) in AM group prior to collection. Median number of HSCs collected post-plerixafor administration was 4.97 x106/kg (range 0.91-34.97) for PM group vs 4.16 x106/kg (range 0.71-9.52) AM group. Total median HSC number collected for patients in the PM group was 6.6x106cells/kg (range 3.14-8.18) vs 5.16x106/kg (range = 2.46-6.45) in the AM group. The AM group had an increased median HSC collected post plerixafor of 83% vs PM median of 75%. A transplantable HSC dose was collected in 97% of those in the AM group and 96% in the PM group. Median number of apheresis procedures with PM dosing was 2 (range 1-5) vs 2.4 with AM dosing (range 1-4). Conclusion: While post plerixafor HSC collection doses were higher with PM dosing this is countered by the total median HSC collection being higher in the AM group. These findings show that same day plerixafor dosing is a feasible option with similar numbers of patients achieving their target HSC collection.

Validation of a post operative complication risk prediction algorithm in a non-head and neck squamous cell carcinoma cohort

Risk-adjusted algorithms in surgical audit attempt to adjust for patient case mix and complexity in order that published outcomes fairly reflect surgical performance and quality of care. Such risk-adjustment models have applied to head and neck squamous cell carcinoma (HNSCC). We test one algorithm, currently embedded in the oncology and reconstruction dataset within the Quality and Outcomes in Oral and Maxillofacial (QOMS) Audit, which is an artificial neural network, for its predictive accuracy on a surgical cohort receiving curative surgery for non-HNSCC pathology. A single centre retrospective case note audit of post operative complications between 2010 and 2020 was conducted on patients having curative surgery for non-HNSCC pathology. The observed complication rate was compared to the predicted probability of complications in order to test the performance of the complication risk-adjustment model. Of 1591 non-HNSCC patients, 58 met the inclusion criteria with a 30-day complication rate of 8/58 (13%). The artificial neural network predicted a complication rate of 20/58 (27%). Sensitivity (0.75), specificity (0.72) and overall accuracy (0.72) suggest acceptable discrimination. Hosmer-Lemershow Goodness of Fit test was good (p = 0.55) suggesting acceptable calibration though over-prediction of complication rate in the highest risk patents was observed. This external validation series suggests the algorithm can be applied to the non-HNSCC cohort, though some refinement of the algorithm is required to account for over-prediction of complications for higher-risk patients. With further analysis a robust means of risk adjusting for the non-HNSCC cohort should be possible.

Hospital in the Home Delivery of Supportive Care for Autologous Stem Cell Transplantation: A Novel Single Centre Patient Focused Approach

Hospital in the Home Delivery of Supportive Care for Autologous Stem Cell Transplantation: A Novel Single Centre Patient Focused Approach

Hospital in the Home Delivery of Conditioning Therapy for Allogeneic Haematopoietic Stem Cell Transplantation: A Novel Single Centre Patient Focused Approach

Introduction: High dose therapy with Allogeneic Haematopoietic Stem Cell Transplantation (AlloHSCT) has traditionally been performed as an inpatient procedure. However, with improvements in supportive care and patient selection it is possible to safely deliver conditioning chemotherapy in an outpatient setting (Subirà M et al., 2003). While deemed an “outpatient procedure” this method is currently delivered on large day units which requires the patient to attend daily, often only spending the night at home.To reduce these daily visits The Royal Melbourne Hospital (RMH) Bone Marrow Transplant department in collaboration with the Hospital in the Home (HIH) department developed an innovative program to safely deliver Fludarabine chemotherapy as part of conditioning for AlloHSCT in the patient's home. This process involved a daily patient review by a HIH Doctor as well as twice daily visits by a HIH nurse to administer chemotherapy and supportive care in the comfort of the patient's home. Here we report on the safety outcomes of HIH AlloHSCT vs inpatient (IP) care, specifically complications and outcomes.Methods: A retrospective case note audit identified 395 consecutive AlloHSCT patients who received Fludarabine based conditioning between 2011 and 2017 at the RMH. Of these 130 received Fludarabine as part of the HIH Program and 265 as a traditional IP.Results: Of those treated as HIH patients, median age was 51 years (range 18-69). 59% patients were male (n=77) and 41% Female (n=53). Underlying disease groups included Leukaemia (n=53; 40%), Lymphoma (n=35; 27%), Myelodysplatic/Myeloproliferative (n=28; 21%), Myeloma (n=11; 9%) and Non-malignant (n=3; 3%). 2% of patients had myeloablative conditioning (n=2) and 98% received Reduced Intensity Conditioning (n=128). 57% (n=73) received stem cells from a sibling (Sib), 41% (n=54) from Voluntary Unrelated Donors (VUD) and 2% (n=3) from Umbilical Cord Donors.Median total Length of Stay (LOS) for HIH patients was 27 days (Range 10-97) with a median of 5 days (range 2-8) at home as part of this. The LOS for those receiving fludarabine as an IP was not significantly different at 26 days (range 5-174; p=0.209). Total number of IP Bed days saved through the HIH program was 682. There was no significant difference in median time to neutrophil engraftment (HIH 20 vs IP 17 days; p =0.95) or platelet engraftment (HIH 23 vs IP 20 days; p=0.99). Having chemotherapy as a HIH patient had no effect on outcome (HR 1.01). There is no difference in Overall Survival (OS) between the two groups (HIH 17 vs IP 16 months - see Figure 1) while Median OS was not reached.Of the 130 patients who were treated in the HIH Program only 11 had an unplanned admission before Day 0 of their AlloHSCT. Reasons for readmission included suspected infection (n=8; only one culture positive), vasovagal (n=1) and anxiety (n=2). Of note, four of these admissions arose in the first three months of the program with the other seven readmissions occurring over the following six years, with a readmission rate of approximately 5% (7/126 patients).Conclusion: The HIH delivery of chemotherapy and supportive care as part of conditioning for AlloHSCT in the patient's home is both safe and effective. It resulted in a median of five bed days saved per patient (Total number of bed days saved = 682), allowing the department to increase bed capacity without the costs associated with building a new ward. Additionally, the risk of complications was low (approximately 5%) and those that did occur were safely managed.Figure 1 - Comparison of Survival Between HIH and IP AlloHSCT Patients [Display omitted] DisclosuresRoutledge:Celgene: Honoraria; Gilead: Honoraria; Bristol-Myers Squibb: Honoraria. Ritchie:Amgen Inc.: Honoraria.

Urine drug screening in women's forensic mental health services: is current practice meeting guidelines?

AimsTo investigate adherence to Trust guidelines for urine drug screening amongst female forensic psychiatric inpatients.BackgroundThe use of illicit substances is an important risk factor which needs to be considered in the management and treatment of forensic psychiatric patients. Research has demonstrated that a high proportion of women admitted within secure services in the UK have a history of substance use. Substance misuse amongst this population can lead to an increased risk of violence, re-offending and mental health relapse; which can pose a significant threat to the safety of other patients, staff and the public. It is therefore important that regular drug screening is carried out to minimise such risks. Ardenleigh is a blended female secure unit in Birmingham. The service has established specific substance use guidelines, outlining the need for each patient to have a personalised drug screen care plan in place. Here we present the findings of an audit completed in 2019.MethodA six month retrospective electronic case note audit for female inpatients admitted to Ardenleigh as of 1st September 2019 (n = 27). We compared drug screen care plans and frequency of urine drug screens over 6 months with the recommendations of the current service-specific Trust guidelines. Care plans should include: information regarding random drug screening; frequency of random drug screening; triggers for increased risk of substance misuse; and consequences for a positive test result to be contained within inpatient care plans.ResultPatient aged between 20 and 56 years old (median age 31). Fewer than half of inpatients (41%) had a documented random drug screen completed within the review period. In terms of care-planning, only 52% of patients had random drug screening mentioned in their care plan. 22% of patient care plans reported the actions/consequences for a positive test result. Not a single care plan mentioned how frequently patients should be being tested or potential triggers for increased risk of drug misuse amongst inpatients.ConclusionCurrent practice and recording of drug screening amongst female forensic psychiatric patients is poor compared to expected standards. The lack of consistency in drug screening raises concerns regarding whether potential substance misuse amongst inpatients may be going undetected, and therefore impacting the recovery of patients. Improvements to drug screening practice should be considered in order to ensure optimal recovery and safety to patients and others.

Is pregnancy status being assessed within women's secure services?

AimsTo establish rates of pregnancy testing on admission of women within a blended secure service.BackgroundWomen with psychiatric illness are known to be at increased risk of pregnancy, often due to engagement in risky sexual behaviours such as having a higher numbers of sexual partners and engaging in sexual activity whilst under the influence of drugs or alcohol. Awareness of pregnancy at the point of admission to psychiatric hospital would inform ongoing care plans to manage the pregnancy in the safest, least restrictive environment and inform future prescribing decisions, to minimise the risk of teratogenicity associated with some psychotropic medications. Ardenleigh in Birmingham is a blended female secure unit. No pregnancy screening guidelines for this population currently exist. This audit sought to establish current rates of pregnancy testing at the point of admission with a view to developing future guidelines.MethodA retrospective case note audit of electronic records of all patients admitted to Ardenleigh blended women's service as of 1st September 2019 (n = 26). The expected standard for pregnancy testing within one month of admission was set as 100%.ResultKey results include: The majority of patients (67%) were aged under 35 years (range 20–56). The most common ethnicities were Caucasian (42%) and African-Caribbean (38%). Almost half (46%) had a primary diagnosis of paranoid schizophrenia.Two women were known to be pregnant at the point of admission. Only 54% of women with an unknown pregnancy status were screened for pregnancy within one month of admission.Rates of screening were particularly poor in women aged under 25 years (43%) and between 36 and 45 (0%).Women not screened for pregnancy were typically admitted from other hospital settings, including AWA services (27%) or other medium secure units (55%). 2 women admitted from prison were not tested (29%)Of those tested, the majority were checked using urine hCG (92%).None of the women tested were found to be pregnant.ConclusionOverall pregnancy testing on admission to the unit was poor, with only 54% of service users screened. Less than 100% compliance could result in serious consequences for both the woman and unborn baby if a pregnancy is not discovered. Updating the admission checklist for Ardenleigh to include pregnancy testing may prove beneficial. It is recommended that a re-audit is completed 6 months following checklist introduction.

Lurasidone for Adolescents With Complex Mental Disorders: A Case Series

Objectives: Lurasidone is a new second generation (atypical) antipsychotic agent with unique receptor affinity and side-effect profiles, but limited literature is available on its use in adolescent populations. Contrasting with research treatment trials which typically recruit patients by stringent selection criteria, this case series examined the effects and tolerability of using lurasidone in adolescents within real-life clinical settings in treating complex cases who had not responded to other therapy options. Methods: We conducted a retrospective case-note audit of 6 adolescents aged 14 to 17 years old attending community child and adolescent mental health services (CAMHS) who were prescribed lurasidone. Results: Lurasidone had been prescribed for a range of “hard-to-manage” conditions with complex comorbidities, in adolescents in relation to specific use of lurasidone on the basis of clinical and pharmacological indications after exhausting more conventional treatment options. Case-note review suggested response to lurasidone was clinically positive in 3 cases, equivocal/marginal in 2 cases, and ineffective in 1 case. There were no cases of poor tolerance or adverse effects. Notably, positive responses for depressive and irritable mood symptoms were specifically recorded by prescribing clinicians, indicative of benefits on symptom improvement. No lurasidone attributed weight gain, galactorrhoea, metabolic abnormalities, sexual dysfunction or intolerance were reported. Pro-cognitive effects were not detected; but our findings were constrained by the non-systematic and incomplete information ascertainment, typical in retrospective case-note review. Conclusion: This case series provides preliminary data supporting lurasidone’s potential use in adolescents of complex clinical needs (but without a clinical diagnosis of bipolar disorder) within real-life clinical settings. Lurasidone appears to show a weight-sparing effect, in addition to improving mood symptoms in some cases. Lurasidone deserves further study for its use in the adolescent population (outside the remit of FDA) given its potential more favorable risk-benefit profile in young people. The favorable tolerability appear to be borne out by the pharmacodynamic predictions in our complex patients who would be excluded in formal clinical trial studies.

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

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

59 Improving the Identification and Management of Delirium in Older Surgical Patients

Abstract Local Problem A multidisciplinary team comprising a consultant geriatrician and nurse consultant reviews all patients aged ≥70 years who have an emergency laparotomy at Royal Derby Hospital. Anecdotally there is a high incidence of delirium but retrospective casenote audit found only 19% of patients admitted for emergency laparotomy July 2018–July 2019 were identified as having delirium by the surgical team. Method A first PDSA cycle showed that the 4AT was feasible for use by healthcare assistants on the surgical assessment unit (SAU). A second PDSA cycle, described here, sought to develop a rationale for implementation of the 4AT as part of surgical assessment by comparing true prevalence of delirium using 4AT, with the prevalence detected using methods currently mandated by our hospital. All patients aged ≥65 years admitted as part of the surgical pathway had 4AT completed by a member of our improvement team on admission, with daily review until discharge. Results Data were collected for 111 consecutive emergency surgical admissions. Mean (SD) age was 78.3 (7.7) years. Of these, 1 and 3 were categorised as having delirium and dementia respectively using existing hospital screening tools. Using 4AT, 36 (32%) of patients were identified as having delirium. When supplemented by clinical history, true prevalence was 40 (36%). Average (SD) length of stay was 7 (5.6) days for the whole cohort, 10 (6.5) and 5.3 (4.3) days for those with and without delirium respectively. Conclusions 4AT was 92% sensitive for delirium in our cohort. The existing hospital tool was underutilised to the point of being useless. Patients with delirium had a longer length of stay. We have developed a modified 4AT paper tool and training materials and are now piloting routine use in SAU.

Advance Care Planning for Adolescents and Young Adults with Cancer: A Retrospective Case Note Audit from a Regional Specialist Center in the United Kingdom.

The extent of Advance Care Planning (ACP) among Adolescent and Young Adult (AYA) cancer patients is not well characterized. This retrospective case note audit scrutinized the records of all AYA patients (aged 16-25 years) known to a regional specialist center in the United Kingdom, and who died between 2013 and 2019, for evidence of ACP. Eighty-four patients were included. ACP was identified for 67% of patients. Sixty-four percent expressed a preferred place of death; actual place of death reflected this in 65% of cases. Creation of a bespoke document may help to standardize ACP and improve end-of-life care.

Early physiotherapy experience with a biodegradable polyurethane dermal substitute: Therapy guidelines for use

ObjectiveThe purpose of this study was to investigate and develop range of motion (ROM) and mobilisation guidelines in adult patients where a newly developed synthetic dermal substitute was applied in our adult burn centre. MethodA retrospective case note audit was conducted on the first 20 acute burn injured patients who had a synthetic dermal substitute applied. Data collected included days to commencement of ROM, days to clearance for mobilisation, and joint ROM achieved after dermal substitute application (prior to delamination) and after split skin grafting (SSG) for the elbow, knee and shoulder joints. Scar assessments were completed at 12 months after injury using two scar assessment scales. ResultsClearance to mobilise occurred at mean 10.4 and 4.9 days after dermal substitute and after skin graft application to lower limbs respectively. ROM commenced at a mean of 9.9 (upper limbs) and 12.7 (lower limbs) days after dermal substitute application. Following skin grafting, ROM commenced at a mean of 6.6 and 6.5 days for upper limbs and lower limbs respectively. Prior to dermal substitute delamination mean flexion at the knee (86.3°), elbow (114.0°) and shoulder (143.4°) was achieved. Mean ROM continued to improve after grafting with knee (133.2°), elbow (126.1°) and shoulder (151.0°) flexion approaching normal ROM in most cases. Mean extension of the elbow (-4.6°) was maintained close to normal levels after skin grafting. There were no recorded instances of knee extension contracture. Patient and Observer Scar Assessment Scale and Matching Assessment of Photographs of Scars scores indicated good cosmetic outcomes with relatively low levels of itch and minimal pain reported at 12 months after injury. ConclusionA steep learning curve was encountered in providing therapy treatment for patients managed with this relatively new synthetic dermal substitute. Trends indicated that as experience with this new dermal substitute grew, patients progressed toward active therapy earlier. A guideline for therapy treatment has been developed but will continue to be evaluated and adjusted when required.

Regional differences in access to acute ischaemic stroke care and patient outcomes.

Advances in stroke management such as acute stroke units and thrombolysis are not uniformly distributed throughout our population, with rural areas being relatively disadvantaged. It remains unclear, however, whether such disparities have led to corresponding differences in patient outcomes. To describe the regional differences in acute ischaemic stroke care and outcomes within the Australian state of Tasmania. A retrospective case note audit was used to assess the care and outcomes of 395 acute ischaemic stroke patients admitted to Tasmania's four major public hospitals. Sixteen care processes were recorded, which covered time-critical treatment, allied health interventions and secondary prevention. Outcome measures were assessed using 30-day mortality and discharge destination, both of which were analysed for differences between urban and rural hospitals using logistic regression. No patients in rural hospitals were administered thrombolysis; these hospitals also did not have acute stroke units. With few exceptions, patients' access to the remaining care indicators was comparable between regions. After adjusting for confounders, there were no significant differences between regions in terms of 30-day mortality (odds ratio (OR) = 0.99, 95% confidence interval (CI) 0.46-2.18) or discharge destination (OR = 1.24, 95% CI 0.81-1.91). With the exception of acute stroke unit care and thrombolysis, acute ischaemic stroke care within Tasmania's urban and rural hospitals was broadly similar. No significant differences were found between regions in terms of patient outcomes. Future studies are encouraged to employ larger data sets, which capture a broader range of urban and rural sites and record patient outcomes at extended interval.

Participation-focused practices in paediatric rehabilitation for children with neurodisability in New Zealand: An observational study using MAPi audit tool.

Participation outcomes and family-centred services are now widely agreed standards of care in paediatric rehabilitation. Evidence suggests that adoption of these practices into usual care has been slow internationally, and no studies of participation-focused or family-centred practices in New Zealand have been undertaken to date. The aims of this study were to identify the extent that goal setting in paediatric rehabilitation services is participation focused and family centred and to profile clinicians' beliefs about these foci. Observational study including a retrospective case note audit and questionnaire. Case notes ('charts') were audited for participation-focused goal-related practice. Subgroup analysis of audit data by service, profession and child ethnicity were completed using weighted mean differences. Clinicians whose case notes were audited completed a 42-item questionnaire on factors related to practice behaviour including text responses with each item. Numerical and text data were analysed descriptively. Five services were recruited (N = 46 clinicians) with case notes for 220 children audited. Auditors extracted 368 potentially participation-related goals (Mdn = 2 goals per child) with no goals extracted for 43 (20%) of case notes. Subsequent coding of extracted goals identified 61% reflected participation (225/368). Subgroup analysis revealed significant differences between services (p = 0.006) and professions (p < 0.001). Clinicians' reported valuing participation outcomes and family involvement and largely felt they did target participation. Skill gaps, absence of self-monitoring strategies and unsupportive professional and work cultures were cited as key challenges. Although valued by clinicians, participation-focused practice is unusual care in paediatric rehabilitation in New Zealand. Substantial gains in the quality of care for children with disabilities could be afforded through training in collaborative goal setting to target participation outcomes.

Safety and Clinical Outcomes of Hospital in the Home.

The aim of the study was to evaluate clinical outcomes and adverse events (AEs) experienced by patients treated within the Hospital in the Home (HITH) service of a major metropolitan hospital in South Australia. A retrospective case note audit of 100 HITH episodes among adults who received continuous intravenous antimicrobial therapy via an elastomeric or electronic infusion device was undertaken. Age- and sex-adjusted binomial logistic regression analyses were undertaken to identify factors associated with major and minor AEs. Of the 100 patients included, 71 were male and the mean (SD) patient age was 62.8 (17.19) years. Elastomeric infusion devices were used for 98 patients. The mean (SD) HITH treatment duration was 20.1 (11.9) days. Overall, 130 AEs were documented for 72 patients (72%), of whom 12 patients experienced a major AE and 68 patients experienced a minor AE. There were 45 occasions among 23 patients where an infusion administered through an elastomeric device did not run to completion. Fifteen patients were readmitted to hospital. Minor AEs were more likely among people with more vascular line days (adjusted odds ratio [aOR] = 1.05; 95% confidence interval (CI) = 1.01-1.10 per day increase) and females (aOR = 4.43; 95% CI = 1.14-17.17). An increased number of vascular line days was associated with an increased likelihood of an incomplete infusion (aOR = 1.05; 95% CI = 1.01-1.09). Hospital readmission was more likely with increasing age (aOR = 1.06; 95% CI = 1.01-1.11 per year increase). Adverse events need to be monitored carefully when HITH treatment is provided for extended periods.

67 Reducing Delays to Operative Management of Anti-Coagulated Patients With Hip Fractures

Abstract Introduction In the UK, the gold-standard treatment of a hip fracture is surgical fixation within 36 hours. Reduced delay to surgery has been shown to minimise the risk of complications. Locally, frequent delays to surgery were observed in patients taking long-term anticoagulation. There are no national guidelines regarding anticoagulation reversal and surgery timing in patients with hip fractures, and doctors are often unfamiliar with increasingly prevalent Direct Oral Anti-coagulants (DOACs). This quality improvement project aimed to reduce delays to surgery in anti-coagulated patients with hip fractures. Methods A guideline was formulated following literature review and consultation with a Consultant Ortho-geriatrician, Orthopaedic Surgeon and Haematologist. Retrospective casenote audit was conducted including 3-month period before and after implementation. The new guideline was disseminated in poster form. Due to the observation that delays in receiving INR results resulted in reversal delay, patient’s on warfarin were recommended to receive 5 mg IV Vitamin K prior to receiving INR results. The INR was rechecked after 6 hours, and if less than 1.6, surgery could proceed. Those on DOACs could undergo surgery 24 hours after the last dose providing eGFR &amp;gt;30, and after 48 hours if eGFR &amp;lt;30. Exclusions were those anti-coagulated for metallic heart valves or recent venous thromboembolism. Results In the 3 months prior to guideline implementation, 71 patients had a hip fracture; 15 were anti-coagulated. Of these, 8 patients were delayed due to their anticoagulation. Repeat audit after implementation, included 46 patients with a hip fracture over the 3-month period; 7 were anti-coagulated. None were delayed due to anticoagulation (p &amp;lt; 0.05). Conclusions This improvement project describes formulation of a simple protocol with evidence from the literature and local expert opinion in order to reduce unnecessary delays in anti-coagulated patients with hip fractures.

Impact of caring for a child born with a neural tube defect on the child and the family: a focus on the coordination of care

Management of children born with neural tube defects (NTDs) is highly complex requiring multidisciplinary care. These children and their families are asked to attend a wide variety of health encounters requiring extensive coordination to facilitate. However, this is not well orchestrated, leading to increased burden on patients and families. The focus of this study was to quantify the volume of hospital encounters for these children, and to investigate the coordination of these visits. We conducted a retrospective case-note audit to review the appointment records of children in the Spina Bifida Clinic at The Royal Children’s Hospital (RCH). Appointment date, outcome and type were collected for the whole duration of the child’s involvement with the hospital. Our cohort was those patients transitioning into the adult system this year. Nine patients were included in total, with varying degrees of disability and different co-morbidities. Between them, there were 1577 attended appointments between 2001 and 2019. The average number of appointments attended annually ranged from 3.3-33.7, and involved input from multiple health disciplines. Outpatient appointments account for over 50% of all hospital encounters, and the 5 most involved specialties are Developmental Medicine, Urology, Physiotherapy, Neurosurgery and Orthopaedics. Cumulatively, these account for almost 80% of all outpatient appointments. Of all appointments the majority (69%) were single appointments. The quantum of hospital encounters is high for families of children with NTDs. Currently, outpatient appointments are sub-optimally coordinated, with most hospital encounters being single appointments. As the majority of the outpatient appointments heavily feature Developmental Medicine, Urology, Physiotherapy, Neurosurgery and Orthopaedics, a multidisciplinary clinic to see all 5 specialists in a single visit should be offered.