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P524: Reducing readmission rate in the elderly population at a District General Hospital
S248
Late Breaker Posters / European Geriatric Medicine 5S1 (2014) S235–S253
of 60/min, Blood pressure of 100/60 mmHg and a temperature of 37°C. The patient had pallor without icterus. Abdomen was distended. There was no guarding nor rigidity out. Bowel sounds were not heard, tympanitic note was present all over the abdomen. Digital rectal examination did not reveal any impacted faeces. On neurological examination, the patient was conscious but. Reflexes was abolished. Laboratoy data showed haemoglobin 10 g/dl, VGM 80 fl, with normal leucocytes. Serum electrolyes showed a hypokaliemiae of 2.5 mmol/l. Renal and liver functions were normal. Initial Electrocardiogram was without abnormalities. A possibility of hypothyroidism was considered in front of anemia and abolished reflexes. Thyroid profile was done and given these results: a low level of Ft4 and high level of TSH. The diagnosis of hypothyroidism was retained. He was started on replacement with thyroxin at the dose of 12.5 ug/day with correction of electrolytes imbalance. In the follow up period, he developped cardiac arrest and couldn’t respond to cardio-pulmonary rescuscitation. Conclusion: Ogilvie’s syndrome may present with many varying clinical situations. Coexisting with hypothyroidism should also be kept in mind. P522 Hypothyroidism in elderly patients: about 71 cases I. Rachdi, M. Lamloum, T. Ben Salem, F. Said, I. Ben Ghorbel, A. Hamzaoui, M. Khanfir, M.H. Houman La Rabta Hospital, Tunisia Introduction: Abnormal thyroid function tests are common for older adults, but the clinical significance of abnormal results and the need for treatment vary. The purpose of this study is to analyse clinical peculiarities of hypothyroidism in elderly population and to identify its principal causes. Patients and Methods: Retrospective survey about cases of hypothyroidism in elderly patients over 65 years in a department of internal medicine within a period of 15 years. Results: It is about 71 patients: 21 men and 50 women. Mean age was 72 years. On past history, we noted cardiac disorders in 65% of patients and a thyroidectomy in 5 cases. Intolerance signs of hypothyroidism were angina and repolarisation disorders at respectively 3% and 21% of cases. The most frequent initial signs revealing the disease were weakness (55%), deterioration of general status (14%), a constipation (10%), a goiter (5%) a dementia (3.5%), a depression (5 cases) and hearing loss (1 case). In others cases, hypothyroidism was discovered when exploring normocytic anemia (2 cases), in front of rythmic cardiac disorders (1 case) or hepatic cytolysis (1 case). Patients had more than 3 symptoms in 51% of cases. The most frequent clinical symptoms were weakness (52%), constipation (18%) and depression (32%). On physical examination, we noted bradycardia, myxoedema and dry skin at respectively 45%, 18% and 6% of patients. Biologic disorders were hyperlipemia in 60% (high levels of triglycerids at (55%), macrocytic anemia at 42%, a hyperhomocysteinemia (1 case), an elevation of muscular enzymes (1 case), hepatic cytolysis (1 case). Hypothyroidism was central in 14% of cases and peripheric in 86%. Very high levels of TSH more than 30UI/l were detected in 50% of cases. Only a case of subclinical hypothyroidism was noted. Main causes were represented by idiopathic primary hypothyroidism at 53% of cases, auto-immune thyroiditis at 25% of cases, secondary to medications: amiodarone at 13% of cases, post thyroid surgery at 7% of cases, secondary to Basedow disease at a case, and to sarcoidosis at a another case. Conclusions: The signs and symptoms of Hypothyroidism in eldery patients are varied and are often not tolerated. Central hypothyroidism seems to be rare. In primary forms, serum levels of TSH are often very high.
Organization of care P523 Experience of the ‘Older Persons Assessment and Liaison (OPAL)’ service in a teaching hospital in Birmingham, UK C.T. Hughes, L. Laghi, Z. Wyrko University Hospitals Birmingham NHS FT, United Kingdom Introduction: In an urban teaching hospital in the United Kingdom multidisciplinary comprehensive geriatric assessment (CGA) was provided to acute admissions aged over 70 years presenting to the Emergency Department (ED) and the Clinical Decisions Unit (CDU). The OPAL team comprised a geriatrician, physiotherapist and nurse specialist. We aimed to evaluate the service through patient outcomes. Methods: Prospective review of all patients admitted to a medical speciality aged 70 years and over for a four week period (19 May to 13 June 2014). Results: During the observed period 547 medical patients were admitted to ED and CDU; 56% (307/547) were assessed by the OPAL team and received CGA. On discharge from ED or CDU, 57% (174/307) returned to their usual place of residence and 8% (25/307) were transferred to community hospitals for ongoing medical or rehabilitation needs. Of those who remained within the acute trust 35% (108/307) were transferred to a medical speciality ward; 47% (51/108) of these were admitted directed to an elderly care ward and 1 patient died. Of those being discharged 53% (164/307) were discharged within 48 hours of admission. The median length of stay was 2 days (range 2 hours to 37 days). Current readmission rate within one month of discharge is 14% (42/307). Conclusion: CGA and multidisciplinary intervention improves the health outcomes for other people [1]. Older people who received CGA at the point of admission appeared to benefit from improved function at discharge, reduced length of stay and increased probability of returning to their usual place of residence on discharge. Reference(s) [1] Ellis G., Whitehead M.A., O’Neill D., Langhorne P., Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2011 Jul 6; (7): CD006211.
P524 Reducing readmission rate in the elderly population at a District General Hospital A.A. Jakupaj, C. Martin-Marero Luton and Dunstable Hospital, Luton, United Kingdom Introduction: The 30-day readmission rate of elderly patients to hospital in the UK is reported as 8–22%. Following the 2011/2012 Payment by Results guidance commissioners will no longer pay for any readmissions within 30 days after discharge, resulting in a cost of £2.2 billion per year to NHS trusts. The aims of this study were to examine factors contributing to readmission rate in elderly patients and to design a strategy to reduce avoidable readmission rates in a District General Hospital. Method: All elderly (age >75) patients who were re-admitted within 30 days of discharge through the emergency department during a 15-day period were included. This cohort was retrospectively analysed for the following factors: age, significant medical comorbidities, inappropriate polypharmacy, length of stay for primary admission and type of ward on discharge. Results: 52 readmissions were identified giving a readmission rate for all wards of 18%. Median age was 84 (range = 75–98). 34 patients (65%) were readmitted with the same problem as their primary admission. 39 patients (75%) had both a significant medical
Late Breaker Posters / European Geriatric Medicine 5S1 (2014) S235–S253
comorbidity and inappropriate polypharmacy. Readmission rates were higher in patients with shorter stay for primary admission who were discharged directly from assessment and short-stay medical units. Conclusion: We find that readmission rates in elderly patients discharged from short-stay medical units are higher than those discharged from elderly care wards. We hypothesise that failure to identify patients at high-risk of readmission in these settings is responsible. We recommend that every patient identified as high-risk should undergo a comprehensive geriatric assessment on admission. We have developed a teaching programme on common frailty syndromes for junior doctors during their induction to emergency medicine. A prospective study is currently being undertaken to validate this. Reference(s) RITCH A. History of Geriatric Medicine: from Hippocrates to Marjory Warren. J R Coll Physicians Edinb 2012; 42:368–74. BARRINGTON R, HYLAND M. The elderly: a challenge to the general hospital. Dublin, Hospital Committee of the European Community, 1994. SCHROOTS JJF, FERNANDEZ-BALLESTEROS R, RUDINGER G. Aging in Europe. IQS Press, Amsterdam 1999. HASTIE Ian R., DUURSMA Sijmen A., (UEMS-GS) Geriatric Medicine In The European Union: Unification Of.
P525 An evaluation of the concept of Flanders Care Living Labs
S249
last financial year there has been a 4.8% increase in A&E attendances and 6% increase in emergency admissions. National data suggests these trends are to continue. Older patients who attend A&E are more likely to be admitted to hospital and also have a longer length of stay. This may reflect the difficulties A&E staff face when assessing the complex elderly patient. Methods: The OPAL team consisting of a Consultant Geriatrician, Occupational Therapist, Physiotherapist and discharge facilitator was introduced to A&E at UHSM. Older patients who presented with geriatric syndromes such as frailty or falls were reviewed by the OPAL team. Patients underwent a CGA in order to instigate appropriate investigations, management and, if able, discharge. Results: Overall 148 patients were reviewed by the OPAL team during the trial period. Only 26% of the patients assessed by the OPAL team were admitted to hospital. This compared to 73% when reviewed by A&E staff alone. Those patients admitted by the OPAL team had a reduced length of stay. Discussion: Older patients have different patterns of disease presentation compared to younger adults. They respond to treatments and therapies in different ways and they frequently have complex social needs that are related to their chronic medical conditions. This data suggests Geriatricians are best skilled to decipher these complex patients and being present in A&E can reduce admissions and length of stay.
C.A.B. Brys1 , L. Pots1 , H. Benichou2 , J. Lemey3 , E. Dessers2 , G. Van Hootegem2 , M. Leys1 , E. Gorus1 , P. De Vriendt3 1 Vrije Universiteit Brussel, Brussels, Belgium; 2 Katholieke Universiteit Leuven, Leuven, Belgium; 3 Artevelde University College, Ghent, Belgium Introduction: In 2012, the Flemish government (Belgium) launched a call for Care Living Labs targeting on innovation in elderly care. The aim is to create new care concepts, services, processes and products, in cooperation with the users, and to test them in real life settings. In a first phase, four Care Living Labs were selected. The ‘Knowledge Innovation Center for Elderly Care’ (KIO) is the scientific consortium responsible for monitoring and evaluating the Care Living Labs. Methods: KIO made a qualitative evaluation of the Care Living Lab designs, based on a document analysis of the submitted proposals. This abstract reports on the evaluation of the underlying designs, e.g. models in ageing and target group, inter-organizational collaboration, task division and job quality. Results: The preliminary evaluation shows three major results. (1) No explicit models are used by the Care Living Labs in order to approach the target group of elderly. The target group is broad and varied, including younger seniors, frail elderly, chronically ill individuals and people with cognitive impairment. (2) Large differences can be seen between the Care Living Labs with regard to the complexity, construction and governance of the interorganizational networks. (3) The four proposals all mention the need for a more integrated care, but seem to lack attention for organizational concepts (like task division and coordination), although related aspects of job quality are taken into account. Conclusions: The preliminary evaluation shows different approaches between the four Care Living Labs, which provides opportunities for further comparative analysis. P526 Comprehensive geriatric assessment (CGA) in the Emergency Department by OPAL (Older People Assessment and Liaison): Does it prevent admissions? S. Scott, E. Bertram Ralph, A. Andrew, R. Ray University Hospital of South Manchester, Manchester, United Kingdom Introduction: The University Hospital of South Manchester (UHSM) covers a large catchment area of around 570,000 patients. Over the
Figure 1. Follow up options.
Figure 2. Length of stay reduction.
P527 Quality of life and meaningful activities in residential care: the Active Ageing (AA) concept challenged P. De Vriendt1 , E. Cornelis2 , V. Desmet2 , R. Vanbosseghem2 , L. Van Malderen1 , E. Gorus1 , D. Van de Velde3 1 Vrije Universiteit Brussel, Brussel Jette, Belgium; 2 Arteveldehogeschool, Ghent, Belgium; 3 UGent, Ghent, Belgium Introduction and Aim: The amount of elderly people living in nursing homes (NH) has risen significantly. Besides promoting autonomy, it is expected that professionals enable residents to engage in meaningful activities, which is closely related to Active Ageing (AA), which is hardly implemented in NH. Factors inhibiting and facilitating being active in the NH, are related to the individual, the environment and residents activity repertoire (AR). This study explores having meaningful activities and influencing factors. Methods: In a survey design, 150 cognitively healthy residents (average 85 years old; ±SD 5.72; range 69–99; 40 men and 86 women) from 40 NH were included. A comprehensive set of global, cognitive, physical, mood and functional assessments was collected, together with a questionnaire on AR. Descriptive statistics
Late Breaker Posters / European Geriatric Medicine 5S1 (2014) S235–S253
of 60/min, Blood pressure of 100/60 mmHg and a temperature of 37°C. The patient had pallor without icterus. Abdomen was distended. There was no guarding nor rigidity out. Bowel sounds were not heard, tympanitic note was present all over the abdomen. Digital rectal examination did not reveal any impacted faeces. On neurological examination, the patient was conscious but. Reflexes was abolished. Laboratoy data showed haemoglobin 10 g/dl, VGM 80 fl, with normal leucocytes. Serum electrolyes showed a hypokaliemiae of 2.5 mmol/l. Renal and liver functions were normal. Initial Electrocardiogram was without abnormalities. A possibility of hypothyroidism was considered in front of anemia and abolished reflexes. Thyroid profile was done and given these results: a low level of Ft4 and high level of TSH. The diagnosis of hypothyroidism was retained. He was started on replacement with thyroxin at the dose of 12.5 ug/day with correction of electrolytes imbalance. In the follow up period, he developped cardiac arrest and couldn’t respond to cardio-pulmonary rescuscitation. Conclusion: Ogilvie’s syndrome may present with many varying clinical situations. Coexisting with hypothyroidism should also be kept in mind. P522 Hypothyroidism in elderly patients: about 71 cases I. Rachdi, M. Lamloum, T. Ben Salem, F. Said, I. Ben Ghorbel, A. Hamzaoui, M. Khanfir, M.H. Houman La Rabta Hospital, Tunisia Introduction: Abnormal thyroid function tests are common for older adults, but the clinical significance of abnormal results and the need for treatment vary. The purpose of this study is to analyse clinical peculiarities of hypothyroidism in elderly population and to identify its principal causes. Patients and Methods: Retrospective survey about cases of hypothyroidism in elderly patients over 65 years in a department of internal medicine within a period of 15 years. Results: It is about 71 patients: 21 men and 50 women. Mean age was 72 years. On past history, we noted cardiac disorders in 65% of patients and a thyroidectomy in 5 cases. Intolerance signs of hypothyroidism were angina and repolarisation disorders at respectively 3% and 21% of cases. The most frequent initial signs revealing the disease were weakness (55%), deterioration of general status (14%), a constipation (10%), a goiter (5%) a dementia (3.5%), a depression (5 cases) and hearing loss (1 case). In others cases, hypothyroidism was discovered when exploring normocytic anemia (2 cases), in front of rythmic cardiac disorders (1 case) or hepatic cytolysis (1 case). Patients had more than 3 symptoms in 51% of cases. The most frequent clinical symptoms were weakness (52%), constipation (18%) and depression (32%). On physical examination, we noted bradycardia, myxoedema and dry skin at respectively 45%, 18% and 6% of patients. Biologic disorders were hyperlipemia in 60% (high levels of triglycerids at (55%), macrocytic anemia at 42%, a hyperhomocysteinemia (1 case), an elevation of muscular enzymes (1 case), hepatic cytolysis (1 case). Hypothyroidism was central in 14% of cases and peripheric in 86%. Very high levels of TSH more than 30UI/l were detected in 50% of cases. Only a case of subclinical hypothyroidism was noted. Main causes were represented by idiopathic primary hypothyroidism at 53% of cases, auto-immune thyroiditis at 25% of cases, secondary to medications: amiodarone at 13% of cases, post thyroid surgery at 7% of cases, secondary to Basedow disease at a case, and to sarcoidosis at a another case. Conclusions: The signs and symptoms of Hypothyroidism in eldery patients are varied and are often not tolerated. Central hypothyroidism seems to be rare. In primary forms, serum levels of TSH are often very high.
Organization of care P523 Experience of the ‘Older Persons Assessment and Liaison (OPAL)’ service in a teaching hospital in Birmingham, UK C.T. Hughes, L. Laghi, Z. Wyrko University Hospitals Birmingham NHS FT, United Kingdom Introduction: In an urban teaching hospital in the United Kingdom multidisciplinary comprehensive geriatric assessment (CGA) was provided to acute admissions aged over 70 years presenting to the Emergency Department (ED) and the Clinical Decisions Unit (CDU). The OPAL team comprised a geriatrician, physiotherapist and nurse specialist. We aimed to evaluate the service through patient outcomes. Methods: Prospective review of all patients admitted to a medical speciality aged 70 years and over for a four week period (19 May to 13 June 2014). Results: During the observed period 547 medical patients were admitted to ED and CDU; 56% (307/547) were assessed by the OPAL team and received CGA. On discharge from ED or CDU, 57% (174/307) returned to their usual place of residence and 8% (25/307) were transferred to community hospitals for ongoing medical or rehabilitation needs. Of those who remained within the acute trust 35% (108/307) were transferred to a medical speciality ward; 47% (51/108) of these were admitted directed to an elderly care ward and 1 patient died. Of those being discharged 53% (164/307) were discharged within 48 hours of admission. The median length of stay was 2 days (range 2 hours to 37 days). Current readmission rate within one month of discharge is 14% (42/307). Conclusion: CGA and multidisciplinary intervention improves the health outcomes for other people [1]. Older people who received CGA at the point of admission appeared to benefit from improved function at discharge, reduced length of stay and increased probability of returning to their usual place of residence on discharge. Reference(s) [1] Ellis G., Whitehead M.A., O’Neill D., Langhorne P., Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2011 Jul 6; (7): CD006211.
P524 Reducing readmission rate in the elderly population at a District General Hospital A.A. Jakupaj, C. Martin-Marero Luton and Dunstable Hospital, Luton, United Kingdom Introduction: The 30-day readmission rate of elderly patients to hospital in the UK is reported as 8–22%. Following the 2011/2012 Payment by Results guidance commissioners will no longer pay for any readmissions within 30 days after discharge, resulting in a cost of £2.2 billion per year to NHS trusts. The aims of this study were to examine factors contributing to readmission rate in elderly patients and to design a strategy to reduce avoidable readmission rates in a District General Hospital. Method: All elderly (age >75) patients who were re-admitted within 30 days of discharge through the emergency department during a 15-day period were included. This cohort was retrospectively analysed for the following factors: age, significant medical comorbidities, inappropriate polypharmacy, length of stay for primary admission and type of ward on discharge. Results: 52 readmissions were identified giving a readmission rate for all wards of 18%. Median age was 84 (range = 75–98). 34 patients (65%) were readmitted with the same problem as their primary admission. 39 patients (75%) had both a significant medical
Late Breaker Posters / European Geriatric Medicine 5S1 (2014) S235–S253
comorbidity and inappropriate polypharmacy. Readmission rates were higher in patients with shorter stay for primary admission who were discharged directly from assessment and short-stay medical units. Conclusion: We find that readmission rates in elderly patients discharged from short-stay medical units are higher than those discharged from elderly care wards. We hypothesise that failure to identify patients at high-risk of readmission in these settings is responsible. We recommend that every patient identified as high-risk should undergo a comprehensive geriatric assessment on admission. We have developed a teaching programme on common frailty syndromes for junior doctors during their induction to emergency medicine. A prospective study is currently being undertaken to validate this. Reference(s) RITCH A. History of Geriatric Medicine: from Hippocrates to Marjory Warren. J R Coll Physicians Edinb 2012; 42:368–74. BARRINGTON R, HYLAND M. The elderly: a challenge to the general hospital. Dublin, Hospital Committee of the European Community, 1994. SCHROOTS JJF, FERNANDEZ-BALLESTEROS R, RUDINGER G. Aging in Europe. IQS Press, Amsterdam 1999. HASTIE Ian R., DUURSMA Sijmen A., (UEMS-GS) Geriatric Medicine In The European Union: Unification Of.
P525 An evaluation of the concept of Flanders Care Living Labs
S249
last financial year there has been a 4.8% increase in A&E attendances and 6% increase in emergency admissions. National data suggests these trends are to continue. Older patients who attend A&E are more likely to be admitted to hospital and also have a longer length of stay. This may reflect the difficulties A&E staff face when assessing the complex elderly patient. Methods: The OPAL team consisting of a Consultant Geriatrician, Occupational Therapist, Physiotherapist and discharge facilitator was introduced to A&E at UHSM. Older patients who presented with geriatric syndromes such as frailty or falls were reviewed by the OPAL team. Patients underwent a CGA in order to instigate appropriate investigations, management and, if able, discharge. Results: Overall 148 patients were reviewed by the OPAL team during the trial period. Only 26% of the patients assessed by the OPAL team were admitted to hospital. This compared to 73% when reviewed by A&E staff alone. Those patients admitted by the OPAL team had a reduced length of stay. Discussion: Older patients have different patterns of disease presentation compared to younger adults. They respond to treatments and therapies in different ways and they frequently have complex social needs that are related to their chronic medical conditions. This data suggests Geriatricians are best skilled to decipher these complex patients and being present in A&E can reduce admissions and length of stay.
C.A.B. Brys1 , L. Pots1 , H. Benichou2 , J. Lemey3 , E. Dessers2 , G. Van Hootegem2 , M. Leys1 , E. Gorus1 , P. De Vriendt3 1 Vrije Universiteit Brussel, Brussels, Belgium; 2 Katholieke Universiteit Leuven, Leuven, Belgium; 3 Artevelde University College, Ghent, Belgium Introduction: In 2012, the Flemish government (Belgium) launched a call for Care Living Labs targeting on innovation in elderly care. The aim is to create new care concepts, services, processes and products, in cooperation with the users, and to test them in real life settings. In a first phase, four Care Living Labs were selected. The ‘Knowledge Innovation Center for Elderly Care’ (KIO) is the scientific consortium responsible for monitoring and evaluating the Care Living Labs. Methods: KIO made a qualitative evaluation of the Care Living Lab designs, based on a document analysis of the submitted proposals. This abstract reports on the evaluation of the underlying designs, e.g. models in ageing and target group, inter-organizational collaboration, task division and job quality. Results: The preliminary evaluation shows three major results. (1) No explicit models are used by the Care Living Labs in order to approach the target group of elderly. The target group is broad and varied, including younger seniors, frail elderly, chronically ill individuals and people with cognitive impairment. (2) Large differences can be seen between the Care Living Labs with regard to the complexity, construction and governance of the interorganizational networks. (3) The four proposals all mention the need for a more integrated care, but seem to lack attention for organizational concepts (like task division and coordination), although related aspects of job quality are taken into account. Conclusions: The preliminary evaluation shows different approaches between the four Care Living Labs, which provides opportunities for further comparative analysis. P526 Comprehensive geriatric assessment (CGA) in the Emergency Department by OPAL (Older People Assessment and Liaison): Does it prevent admissions? S. Scott, E. Bertram Ralph, A. Andrew, R. Ray University Hospital of South Manchester, Manchester, United Kingdom Introduction: The University Hospital of South Manchester (UHSM) covers a large catchment area of around 570,000 patients. Over the
Figure 1. Follow up options.
Figure 2. Length of stay reduction.
P527 Quality of life and meaningful activities in residential care: the Active Ageing (AA) concept challenged P. De Vriendt1 , E. Cornelis2 , V. Desmet2 , R. Vanbosseghem2 , L. Van Malderen1 , E. Gorus1 , D. Van de Velde3 1 Vrije Universiteit Brussel, Brussel Jette, Belgium; 2 Arteveldehogeschool, Ghent, Belgium; 3 UGent, Ghent, Belgium Introduction and Aim: The amount of elderly people living in nursing homes (NH) has risen significantly. Besides promoting autonomy, it is expected that professionals enable residents to engage in meaningful activities, which is closely related to Active Ageing (AA), which is hardly implemented in NH. Factors inhibiting and facilitating being active in the NH, are related to the individual, the environment and residents activity repertoire (AR). This study explores having meaningful activities and influencing factors. Methods: In a survey design, 150 cognitively healthy residents (average 85 years old; ±SD 5.72; range 69–99; 40 men and 86 women) from 40 NH were included. A comprehensive set of global, cognitive, physical, mood and functional assessments was collected, together with a questionnaire on AR. Descriptive statistics