Abstract
Background
Quarantine, lockdowns and mandatory isolation have slowed the transmission of Covid-19. However, these public health measures have amplified frailty in our vulnerable older person ...population by increasing social disconnection, reducing exercise and access to early interventions. In response to this increasingly dependent older population we introduced a ‘frailty hub’ in our hospital. This hub allowed early access to a geriatric review as well as a broader multidisciplinary team intervention.
Methods
We performed a cross sectional review of our new hub which was introduced in our tertiary centre to priortise care of the older person.We analysed attendees from February to June 2021 (20 weeks of data).
Results
There were 121 new patient reviews and 127 follow up consultations.Commonly requested reason for referral was medical assessment (30%), cognitive assessments (30%) and falls(28%). Referral sources were analysed and included consultant referrals (11% n = 13), GP referrals (55% n = 67), multidisciplinary team referrals (6% n = 7) and emergency department referrals (26% n = 32). The average age of those review was 79 years (range 59 years to 99 years). Of all patients 65% were reviewed by physiotherapist, 45% were seen by an occupational therapist, 10% were seen by a speech and language therapist or dietician. 85% had a medication changes. 95% had a follow up review with either a geriatrician or advanced nurse practitioner.
Conclusion
Innovation is required to appropriately target our most vulnerable frail adults.The pandemic has had a detrimental effect on some older adult’s function.Our hub is targeting this group and optimising their care.These are our preliminary findings, we plan on doing further analysis.
Abstract
Background
Older adults are at high risk from coronavirus 2019 (COVID-19). Even with the introduction of a widespread vaccination programme, adherence to public health guidelines continue to ...be of vital importance to reducing the spread of COVID-19. This study examines the factors associated with adherence to two public health guidelines, social distancing and mask wearing, among older adults (50 years and over) in Ireland.
Methods
Data from the Irish Longitudinal Study on Ageing (TILDA) COVID-19 study and previous waves of TILDA was used. The COVID-19 study data was collected between July 2020 and November 2020. Logistic regression analysis was conducted separately to examine the relationship between the independent variables and social distancing and mask wearing respectively. Along with socio-demographic variables, the Health Belief Model (HBM) was used to identify variables for inclusion in the analysis.
Results
In total, 2,816 participants were included in this study. Females were more likely than males to adhere to social distancing and mask wearing guidelines. Those most concerned about COVID-19 were more likely to adhere to both behaviours. Education levels were associated with adherence to both behaviours but the direction of the relationship differed. Those who trusted the Health Service Executive as a news source were more likely to socially distance, while those with less understanding of government guidance and those who trusted in government news sources were less likely to socially distance. Participants who were working were less likely to socially distance than those who weren’t. While, participants who were over 70 and those who returned the survey after the introduction of mandatory mask wearing were more likely to wear a mask. Participants who lived outside of Dublin were less likely to wear a mask.
Conclusion
Factors associated with adherence to public health guidelines vary according to the guideline. Differences between groups need to be considered when implementing policy around public health guidelines.
Abstract
Background
The WHO declared COVID-19 a pandemic in March 2020. Specific public health measures were implemented for older adults who were advised to ‘cocoon’. While this has a positive ...effect on disease spread, reduced activity increases the risk of falls and fractures as well as all-cause mortality 1. The New Mobility Score(NMS) stratifies patients according to pre-fracture mobility and predicts 6-month functional level and 1-year mortality 2. Using the NMS, we evaluated patient mobility pre and post-restrictions. We also obtained basic data, frequency of falls and Clinical Frailty Scale (CFS).
Methods
We prospectively studied 50 patients admitted with a fracture and reviewed by our Orthogeriatric team between August–October 2020.
Results
Mean age was 80 years range 53–99, 41(82%) were over 70 years and 43 (86%) were female. A hip fracture, 39 (78%) was the most common admission and mean CFS was 4 Range 1–7 classifying the cohort as mildly frail. Mean NMS was significantly lower post-restrictions compared to pre-restrictions 5 SD 2.19 vs 6.5 SD 2.15 P = 0.0074. There was no difference in falls pre and post-restrictions 1.1 S.D 2.3 vs 1.9 S.D 1.9 P = 0.0609.
Conclusion
Our study shows that in a vulnerable cohort, COVID-19 restrictions have significantly impacted mobility over a short time period. As a result, our patients are less likely to regain pre-fracture functional level and are at increased risk of all-cause mortality. As further restrictions are implemented, public health strategies for older adults should be prioritised to maintain mobility and prevent adverse outcomes.
References
1. Cunningham C et al. Consequences of physical inactivity in older adults: a systematic review of reviews and meta-analyses. Scand J Med Sci Sports. 2020;00:1–12. 10.1111/sms.13616.
2. Kristensen MT et al. Prefracture functional level evaluated by the New Mobility Score predicts in-hospital outcome after hip fracture surgery. Acta Orthop. 2010;81(3):296–302. 10.3109/17453674.2010.487240.
Abstract
Background
The COVID19 pandemic highlighted deficiencies in interdisciplinary risk-communication in an intermediate care unit, based in a 30 bed independent care home, into which the ...hospital organisation assigns medical, pharmacy, physiotherapy, occupational therapy and social work teams to provide post-acute care rehabilitation for adults. Mean length of stay is 20 days and > 75% return home. Weekly bed turnover is approximately 15%.
Methods
Semi-structured interviews with nursing leaders and a weighted questionnaire for multidisciplinary team were used to determine baseline levels of confidence around environmental and resident-specific risk awareness.
An Ishikawa diagram analysed factors contributing to risk-communication. The ‘Chain Of Care’ vision for care home environments incorporated a Multidisciplinary Safety Brief. Five iterations occurred before reaching standardisation. A post-implementation weighted questionnaire collated qualitative information on confidence change.
The Safety Brief supplements intra-professional group handover processes. Duration ranged 90-120 seconds, occurring at shift commencement and 12.00 h daily. Retained documentation is available for inspectors.
Results
The Safety Brief as a communication tool: 86% of the team found it useful; 71% found that it had the ‘right amount’ of detail; and 62% found that it was of the ‘right duration’.
Areas of greatest ‘swing’ towards INCREASED or SLIGHTLY INCREASED confidence in awareness of...: 72%, deaths in last 24 hours; 68%, planned discharges today; 67%, residents at risk of falling/had fallen within 48 hours; 67%, residents with same name; 66%, bed-availability; 63%, infection risks; 62%, experiencing delirium; 62%, living with dementia; 59%, scheduled appointments today; and 52%, those receiving palliative care.
Conclusion
A Multidisciplinary Safety Brief increased/slightly increased multidisciplinary team confidence in environmental and resident-specific risks in a care home environment. Risk-communication in any environment is complex especially if subject to frequent change. Communication tools need to be tailored to microsystem, systematic, comprehensive, yet brief and intuitive. Generalisability to non-intermediate care, non-geriatrician supported care home environments was considered iteratively.
Abstract
Background
The disproportionately high death rate of nursing home (NH) residents from COVID-19 in many countries, including Ireland, has focussed attention on infection prevention and ...control, including the built environment, in nursing homes. This has been a poorly researched topic to date, and we undertook a systematic review of evidence for architectural design measures which support infection control and pandemic preparedness.
Methods
Databases were screened for keywords related to NHs, built environment, infection prevention and control, and COVID-19; relevant papers were uploaded onto Covidence and screened for relevance. Data extracted from included articles was tabulated under 8 specific aspects of the built environment.
Results
Of 17 papers included in the final analysis, four studies found that larger nursing homes carried an increased risk of COVID-19 infection. Crowding in NHs was also a risk factor for infection, with a high crowding index associated with COVID-19 infection in five studies. Green House care homes, which are based on small clusters of domestic dwellings, fared better than traditional NHs. Two papers found an association between the location of NHs and the risk of COVID-19 infection, with urban NHs and those in areas of high prevalence being more at risk. Two papers identified internal fittings as a target for infection prevention and control. Seven papers highlighted the role of adequate ventilation in NHs in the prevention of spread of COVID-19. Only one paper described easy access to the outdoors as beneficial to infection control.
Conclusion
Residents of NHs are amongst the most vulnerable to COVID-19 infection. When designing and building NHs, the role of the built environment in controlling the spread of the virus should not be underestimated.
This research supported by Science Foundation Ireland.
Abstract
Background
Severe acute respiratory coronavirus 2 (SARS-CoV-2) was first recorded in Ireland in February 2020. Several studies have explored the association between age and SARS-CoV-2, ...showing that there were poorer outcomes in older people. Our objective was to evaluate the impact of age on outcomes such as hospital length of stay, mortality, and re-hospitalisation.
Methods
We performed a single-centre, retrospective observational cohort study, using an electronic microbiology database of recorded index admissions of SARS-CoV-2 positive patients aged 65 years and older during SARS-CoV-2 wave one (March 1st to May 31st 2020). PCR testing of nasopharyngeal and/or sputum samples was used to confirm positivity. Our clinical outcomes measured included hospital length of stay, mortality and re-admission rate within 6 months.
Results
153 patients 65 years and above were admitted. The male to female ratio was 1.3 with 90% admitted medically. 79 patients were aged between 65–79 years; 84 patients ≥80 years; and 12 patients ≥90 years. Mortality was 25%, 31% and 42%, respectively. Median length of stay remained 14 days for ages 65–89 rising to 17.5 days for those ≥90 years. Re-hospitalisation rates at 6 months were similar for ages 65–79 and 89–89 years at 42% and 40%, respectively. One patient (14%) over 90 years was re-hospitalised.
Conclusion
SARS-CoV-2 has disproportionately impacted on general medical services treating older hospitalised people. In our centre, mortality for patients ≥65 years was 28.1% which compared favourably with 35.6% internationally as outlined by Victor et al. (2020) based on Spanish data. Treatment of SARS-CoV-2 is not futile in older patients with 58% of nonagenarians and 69% of octogenarians surviving, however re-hospitalisation rates are high at 40%. A targeted approach to discharge support via integrated care may ameliorate this.
Abstract
Background
The COVID19 pandemic highlighted deficiencies in information exchange in nursing handover in an intermediate care unit, based in a 30 bed independent care home, into which the ...hospital organisation assigns a multidisciplinary team to provide post-acute care rehabilitation for adults. Mean length of stay is 20 days and > 75% return home. Weekly bed turnover is approximately 15%. A revised electronic template was developed to complement an Intermediate Care Framework already in use, based on National Audit of Intermediate Care quality indicators.
Methods
Semi-structured interviews with nursing leaders and a weighted questionnaire for the whole nursing team were used to determine baseline levels of confidence around aspects of nursing handover.
An Ishikawa diagram analysed factors contributing to poor documentation and communication. The ‘Chain Of Care’ vision for care home environments incorporated the need for microsystem-tailored, standardised, integrated nursing handover. Four iterations occurred. A post-implementation weighted questionnaire collated qualitative information on confidence change.
Results
Areas of greatest ‘swing’ towards INCREASED or SLIGHTLY INCREASED confidence around...: 70%, addressing questions from residents or relatives; 70%, responding to change in a resident’s health status; 70%, giving handover to ambulance crew or doctor or fellow nurse.
Conclusion
Categorical selections across multiple information domains enabled increased/slightly increased confidence in the nursing team in the quality of the information exchanged in nursing handover in an intermediate care rehabilitation care-home setting. Focussed, free-text options permit narrative if required.
A shared electronic template facilitated accessibility and live-time editing in an environment with relatively higher bed-turnover and frequently changing functional mobility and care needs of residents.
Tailoring the nursing handover to the intermediate care environment with mitigation of variation of information provision/accessibility/language were considered in the iterations. Versions are reposited for inspectors.
Abstract
Background
The COVID19 pandemic highlighted deficiencies in the recognition, monitoring, escalation and de-escalation of the acutely unwell care home resident. RESTORE2 is endorsed by the ...British Geriatric Society as the preferred tool for use in a care home setting. It incorporates: recognition of soft-signs; NEWS2 (National Early Warning Score 2); and SBAR-D (Situation Background Assessment Recommendation-Decision). Implementing RESTORE2 required a series of change interventions in a mesosystem environment in intermediate care bed-based rehabilitation setting in an independent care home.
Methods
The Flow Coaching Academy ‘5Vs’ Framework was used. A vision of ‘CHAIN of CARE’ was developed (Care Home Assessment of Intervention Need and Communicate Act Review Evaluate). Stake-holder mapping was undertaken. A Sinek Circle distilled intentions. A global aim led to specific aims and informed driver diagrams. Problems and risks were mapped out with an Ishikawa diagram. A high-level process map of future state was and cross-functional swim-lane chart for RESTORE2 use were devised. A clinical value compass map was used to consider outcomes. PDSA cycles were used.
Results
The FCA Framework methodology, albeit without the ability to undertake ‘Big Room’ meetings due to the COVID19 pandemic restrictions, enabled the development of a care-home tailored Treatment Escalation Plan; an electronic template Nursing Handover; Multidisciplinary Safety Brief; training of all nursing team in RESTORE2; and use of NEWS2 for all residents in the intermediate care setting. Additional prompt for how to use RESTORE2 was developed.
Conclusion
Bringing about complex change in a complex mesosystem benefits from different techniques than microsystem change methodology. The 5Vs: Visualisation, Vision, Value, eVidence and inVolvement in the FCA Framework are an effective approach. The residents’ voice was largely absent in the pressures of the COVID19 pandemic.
‘The Chain of Care’ proved helpful in visualising the global aims for the clinical team.
Abstract
Background
Cardiovascular diseases (CVDs) are consistently ranked among the leading causes of death among older adults in Ireland. COVID-19 and influenza infection are associated with ...cardiovascular complications. However, percentage of deaths caused by CVD among adults aged 75 and over in Ireland decreased from 32.9% to 31.0% from 2019 to 2020. Government-imposed social distancing measures resulted in abolition of influenza activity (IA). We analysed population data from the 2010/11–2019/20 influenza seasons to estimate the impact of reduced IA on CVD mortality rates during the COVID-19 pandemic season.
Methods
Quarterly mortality data for acute myocardial infarction (AMI) and cerebrovascular disease from first quarter (Q1) 2010 to fourth quarter (Q4) 2020 was obtained from the Central Statistics Office. Weekly data on influenza-like illness (ILI) rates and positive percentages (PP) (i.e. proportion of influenza-positive sentinel respiratory specimens) from week 40 2010 to week 20 2020 was obtained from the Health Protection Surveillance Centre. Excess mortality rate during influenza season was calculated as the percentage difference between Q4/Q1 and preceding third quarter (Q3) mortality rates. We adopted the Goldstein index (ILI rate × PP) as an indicator of IA. Time series analyses, Pearson correlation coefficients (r) and linear regression models were used to evaluate the relationships between IA and excess AMI and cerebrovascular disease mortality rates.
Results
Statistically significant positive associations were observed between IA and excess AMI (r = 0.557, p = 0.011) and cerebrovascular disease (r = 0.858, p < 0.001) mortality rates. Linear regression models predicted 0.072% (95% confidence interval 0.019%, 0.125%) and 0.095% (0.067%, 0.123%) increases in excess AMI and cerebrovascular disease mortality rates respectively per unit increase in IA levels.
Conclusion
Elimination of IA may have contributed towards limiting the effects of COVID-19 on CVD mortality rates, and consequently total excess mortality, among older adults in Ireland.
Abstract
Background
‘What Matters to You’(WMTY) is a routine question in the comprehensive geriatric assessment (CGA) of the frail older person. The aim was to categorise WMTY and investigate changes ...during COVID-19.
Methods
WMTY, clinical frailty score (CFS), age, gender, vision and hearing impairment, malnutrition risk, modified Barthel Index (mBI), living alone status, 4AT and dementia screening results were prospectively entered onto MS Excel. Answers were retrospectively categorised and compared, pre-COVID-19 (April to June 2019) and during COVID-19 (April to June 2020). Descriptive statistics and MS Excel T-test were used for data analysis.
Results
The mean CFS (5), age (82 years), male: female ratio (1:1.3), prevalence of visual and hearing impairment (20–30%) and malnutrition risk were similar (23%) in both groups mBI was non-significantly reduced by a 1 point average during COVID-19.
Less patients lived alone during COVID-19 (p = 0.05). Positive delirium screen doubled (12% vs 26%) during COVID-19. Positive dementia screen doubled (10% vs 20%) during COVID-19.
Themes in decreasing order were family, health, home, functional independence, pets, discharge plan, religion, work, social activities and other pre-COVID-19. Family and health accounted for 49% of responses.
During COVID-19, the order changed to health, family and home, functional independence, work and discharge planning, pets, religion and social activities.
There was a 50% increase in functional independence as a response, a 40% increase in home and a 58% decrease in family as a response.
Conclusion
Cognitive vulnerability doubled during COVID-19. Nine themes were identified. WMTY themes shifted during COVID-19. Health become the most frequent response. Family became a less frequent response with less people living alone. Functional independence was more frequent reflecting the need for self-reliance during COVID-19. Home, where all COVID-19 life was lived, was expressed as WMTY by a greater number of respondents. Promotion of functional independence has been identified as a key driver for practice change.
