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P-434: Predicting 30 day mortality after hip fracture: validating the use of National Hip Fracture Database (NHFD) data
S148
Poster presentations / European Geriatric Medicine 6S1 (2015) S32–S156
P-432 Perioperative Comprehensive Geriatric Assessment is associated with reduced inpatient length of stay S. Singh1 , R. Hodgkinson1 , D. Shipway2 , K. Moorthy3 Imperial NHS Trust, London, United Kingdom; 2 United Kingdom; 3 Upper GI Surgery, St Mary’s Hospital, Imperial College Healthcare Trust, United Kingdom, London, United Kingdom
1
Objectives: Older surgical patients are frail and often have multimorbidity. They develop more perioperative medical complications and have longer inpatient length of stay (LOS). Current guidelines state that best practice for older people undergoing surgery should involve comprehensive geriatric assessment (CGA) and access to a geriatrician. CGA reduces inpatient LOS and medical complications in older patients undergoing orthopaedic surgery, but limited data exists evaluating its impact in other surgical populations. We aimed to investigate whether a CGA approach for older patients undergoing gastrointestinal cancer surgery could also reduce inpatient LOS in an urban tertiary referral surgical unit. Methods: We established a geriatrician-led CGA liaison service for patients aged 70 and over undergoing surgery for gastrointestinal cancer. Pre-operative CGA was conducted in a rapid-access outpatient clinic directly after diagnosis for patients deemed to be high risk either as a result of frailty or multimorbidity. Proactive post-operative multidisciplinary medical and therapy support was embedded on the surgical ward to provide early post-operative medical review and rehabilitation. Results: We calculated the LOS for patients undergoing gastrointestinal cancer surgery aged 70 and over in a 6 month period both before and after the introduction of the CGA liaison service. There was a 31% reduction in the LOS following the intervention. Conclusions: Perioperative CGA and post-operative geriatrician support is associated with reduced inpatient LOS in patients aged 70 and over undergoing gastrointestinal cancer surgery.
Total LOS Mean LOS (days)
Pre-intervention (32 patients)
Post-intervention (42 patients)
423 13.2
383 9.1
P-433 Differences in baseline characteristics and outcomes of older persons requiring hospital admission after introduction of an elderly care in reach service. Perioperative care of older people undergoing surgery – Salford General Surgery (POPS-SG) D. Houghton1 , S. Krepple2 , A. Vilches-Moraga2 , J. Fox2 , T. Thorpe1 , K. Wardle2 , M.K. Peeroo2 , E. Feilding2 , Z.R. Alio2 1 Salford Royal NHS Foundation Trust, Salford, United Kingdom; 2 Salford Royal NHS Foundation Trust, Salford, Manchester, United Kingdom Objectives: The purpose of our study was to describe the impact of an elderly care in reach service on patient outcomes. Methods: We compared all surgical patients (general, colorectal or upper gastrointestinal) over the age of 74 discharged from hospital between February 1st and March 31st 2014 with those assessed by our in reach Service between February 1st and March 31st 2015. Results: Initial group (IG) (n 53) patients’ mean age was 81.3 years, 50% females, 81% emergencies, two in-hospital deaths, 3.7% deaths and 20.7% readmissions before day 30. Length of stay was 10 days and 28% required review by generalists. Our in-reach team (IR) assessed 63 individuals with a mean age of 81.4 years, 39% females, 79% emergencies, 4 in-hospital deaths, 0 deaths and17.4% readmissions before day 30. Length of stay was 12 days and 23% required non-surgical reviews.
Present complains and diagnoses were similar (abdominal pain and vomiting, cholecystitis and cancer). IG Patients had 3 comorbidities on average compared to 5.1 and took 6.3 medications compared to 8.2. 49% of IG patients underwent medication review as opposed to 100% IR (with an average reduction of 2 medications). There was a significant increase in the recognition of complications i.e. anaemia (5.6 vs. 57.1%), acute kidney injury (1.8 vs. 31.7%) and constipation (1.8 vs. 61.9%). Conclusions: An elderly care in reach service was able to increase comorbidity and complication recognition, medication optimisation and reduce out of hours reviews by non surgical specialists. There was no significant change in clinical outcomes. P-434 Predicting 30 day mortality after hip fracture: validating the use of National Hip Fracture Database (NHFD) data A. Johansen1 , C. Tsang2 , D. Cromwell2 , C. Boulton1 , R. Wakeman1 , V. Burgon1 1 National Hip Fracture Database, London, United Kingdom; 2 Clinical Effectiveness Unit, Royal College of Surgeons of England, London, United Kingdom Objectives: The NHFD and Royal College of Surgeons of England (RCS) have described a model with six predictive factors from the NHFD dataset for casemix adjustment of 30 day mortality. Several other outcome prediction tools have previously been described. We set out to compare the NHFD-RCS model with the most widely used of these – the Nottingham hip fracture score. Methods: We used the expanded dataset of our 2013 Anaesthetic Sprint Audit of Practice (ASAP) – data for 7,906 patients aged 60+ years, who had hip fracture surgery in May–July 2013. We linked to Office of National Statistics death data to identify patients’ mortality status 30 days after admission. We used the first six weeks’ data (4,045 patients) to recalibrate the models, and the next six weeks’ data (3,861 patients) to validate them. Multiple imputation was used to manage missing data. Results: Several variables (AMT score, fracture type, some individual comorbidities) were not significant predictors in univariate analyses. After adjusting for other patient characteristics we found age, sex, ASA grade (NHFD-RCS model), and number of comorbidities (Nottingham score) to be the strongest predictors. Both models displayed similar discriminative power; the highest cstatistic achieved by each being 0.74. Both models over-estimated mortality risk for patients in highest risk groups. Conclusions: Both models achieved moderate predictive performance. In further work using NHFD data, we will explore the scope for additional NHFD fields (eg. AMT score and deprivation) to improve the NHFD-RCS model’s performance – for use with individual patients and in hospital benchmarking. P-435 Hip fracture following an inpatient fall: using the National Hip Fracture Database (NHFD) to identify the true scale of this challenge A. Johansen1 , C. Boulton1 , V. Burgon1 , F. Martin2 , R. Stanley1 , R. Wakeman1 , A. Williams1 1 National Hip Fracture Database, London, United Kingdom; 2 Guys and St Thomas’ Hospitals NHS Trust, London, United Kingdom Objectives: Hip fracture outcome is especially poor for people who sustain this injury while an inpatient. Pre-existing medical and psychiatric problems often prove challenging. In 2009 the UK’s National Patient Safety Agency (NPSA) identified 840 hip fractures after inpatient falls. We set out to identify the true incidence of such presentations. Methods: During 2013 the NHFD collected data from all 182 trauma units in England, Wales and Northern Ireland. We identified 64,838 hip fractures in people aged >60; over 95% of all such fractures. We
Poster presentations / European Geriatric Medicine 6S1 (2015) S32–S156
P-432 Perioperative Comprehensive Geriatric Assessment is associated with reduced inpatient length of stay S. Singh1 , R. Hodgkinson1 , D. Shipway2 , K. Moorthy3 Imperial NHS Trust, London, United Kingdom; 2 United Kingdom; 3 Upper GI Surgery, St Mary’s Hospital, Imperial College Healthcare Trust, United Kingdom, London, United Kingdom
1
Objectives: Older surgical patients are frail and often have multimorbidity. They develop more perioperative medical complications and have longer inpatient length of stay (LOS). Current guidelines state that best practice for older people undergoing surgery should involve comprehensive geriatric assessment (CGA) and access to a geriatrician. CGA reduces inpatient LOS and medical complications in older patients undergoing orthopaedic surgery, but limited data exists evaluating its impact in other surgical populations. We aimed to investigate whether a CGA approach for older patients undergoing gastrointestinal cancer surgery could also reduce inpatient LOS in an urban tertiary referral surgical unit. Methods: We established a geriatrician-led CGA liaison service for patients aged 70 and over undergoing surgery for gastrointestinal cancer. Pre-operative CGA was conducted in a rapid-access outpatient clinic directly after diagnosis for patients deemed to be high risk either as a result of frailty or multimorbidity. Proactive post-operative multidisciplinary medical and therapy support was embedded on the surgical ward to provide early post-operative medical review and rehabilitation. Results: We calculated the LOS for patients undergoing gastrointestinal cancer surgery aged 70 and over in a 6 month period both before and after the introduction of the CGA liaison service. There was a 31% reduction in the LOS following the intervention. Conclusions: Perioperative CGA and post-operative geriatrician support is associated with reduced inpatient LOS in patients aged 70 and over undergoing gastrointestinal cancer surgery.
Total LOS Mean LOS (days)
Pre-intervention (32 patients)
Post-intervention (42 patients)
423 13.2
383 9.1
P-433 Differences in baseline characteristics and outcomes of older persons requiring hospital admission after introduction of an elderly care in reach service. Perioperative care of older people undergoing surgery – Salford General Surgery (POPS-SG) D. Houghton1 , S. Krepple2 , A. Vilches-Moraga2 , J. Fox2 , T. Thorpe1 , K. Wardle2 , M.K. Peeroo2 , E. Feilding2 , Z.R. Alio2 1 Salford Royal NHS Foundation Trust, Salford, United Kingdom; 2 Salford Royal NHS Foundation Trust, Salford, Manchester, United Kingdom Objectives: The purpose of our study was to describe the impact of an elderly care in reach service on patient outcomes. Methods: We compared all surgical patients (general, colorectal or upper gastrointestinal) over the age of 74 discharged from hospital between February 1st and March 31st 2014 with those assessed by our in reach Service between February 1st and March 31st 2015. Results: Initial group (IG) (n 53) patients’ mean age was 81.3 years, 50% females, 81% emergencies, two in-hospital deaths, 3.7% deaths and 20.7% readmissions before day 30. Length of stay was 10 days and 28% required review by generalists. Our in-reach team (IR) assessed 63 individuals with a mean age of 81.4 years, 39% females, 79% emergencies, 4 in-hospital deaths, 0 deaths and17.4% readmissions before day 30. Length of stay was 12 days and 23% required non-surgical reviews.
Present complains and diagnoses were similar (abdominal pain and vomiting, cholecystitis and cancer). IG Patients had 3 comorbidities on average compared to 5.1 and took 6.3 medications compared to 8.2. 49% of IG patients underwent medication review as opposed to 100% IR (with an average reduction of 2 medications). There was a significant increase in the recognition of complications i.e. anaemia (5.6 vs. 57.1%), acute kidney injury (1.8 vs. 31.7%) and constipation (1.8 vs. 61.9%). Conclusions: An elderly care in reach service was able to increase comorbidity and complication recognition, medication optimisation and reduce out of hours reviews by non surgical specialists. There was no significant change in clinical outcomes. P-434 Predicting 30 day mortality after hip fracture: validating the use of National Hip Fracture Database (NHFD) data A. Johansen1 , C. Tsang2 , D. Cromwell2 , C. Boulton1 , R. Wakeman1 , V. Burgon1 1 National Hip Fracture Database, London, United Kingdom; 2 Clinical Effectiveness Unit, Royal College of Surgeons of England, London, United Kingdom Objectives: The NHFD and Royal College of Surgeons of England (RCS) have described a model with six predictive factors from the NHFD dataset for casemix adjustment of 30 day mortality. Several other outcome prediction tools have previously been described. We set out to compare the NHFD-RCS model with the most widely used of these – the Nottingham hip fracture score. Methods: We used the expanded dataset of our 2013 Anaesthetic Sprint Audit of Practice (ASAP) – data for 7,906 patients aged 60+ years, who had hip fracture surgery in May–July 2013. We linked to Office of National Statistics death data to identify patients’ mortality status 30 days after admission. We used the first six weeks’ data (4,045 patients) to recalibrate the models, and the next six weeks’ data (3,861 patients) to validate them. Multiple imputation was used to manage missing data. Results: Several variables (AMT score, fracture type, some individual comorbidities) were not significant predictors in univariate analyses. After adjusting for other patient characteristics we found age, sex, ASA grade (NHFD-RCS model), and number of comorbidities (Nottingham score) to be the strongest predictors. Both models displayed similar discriminative power; the highest cstatistic achieved by each being 0.74. Both models over-estimated mortality risk for patients in highest risk groups. Conclusions: Both models achieved moderate predictive performance. In further work using NHFD data, we will explore the scope for additional NHFD fields (eg. AMT score and deprivation) to improve the NHFD-RCS model’s performance – for use with individual patients and in hospital benchmarking. P-435 Hip fracture following an inpatient fall: using the National Hip Fracture Database (NHFD) to identify the true scale of this challenge A. Johansen1 , C. Boulton1 , V. Burgon1 , F. Martin2 , R. Stanley1 , R. Wakeman1 , A. Williams1 1 National Hip Fracture Database, London, United Kingdom; 2 Guys and St Thomas’ Hospitals NHS Trust, London, United Kingdom Objectives: Hip fracture outcome is especially poor for people who sustain this injury while an inpatient. Pre-existing medical and psychiatric problems often prove challenging. In 2009 the UK’s National Patient Safety Agency (NPSA) identified 840 hip fractures after inpatient falls. We set out to identify the true incidence of such presentations. Methods: During 2013 the NHFD collected data from all 182 trauma units in England, Wales and Northern Ireland. We identified 64,838 hip fractures in people aged >60; over 95% of all such fractures. We