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Objective: This study explores whether “future” lighting systems that provide greater control and opportunity for circadian synchronization are acceptable to participants in the role of patients. Background: Tunable, dimmable light emitting diode systems provide multiple potential benefits for healthcare. They can provide significant energy savings, support circadian synchronization by varying the spectrum and intensity of light over the course of the day, address nighttime navigation needs, and provide user-friendly control. There is an emerging understanding of the important visual and nonvisual effects of light; however, important questions remain about the experience and acceptability of this “future” lighting if we are to adopt it broadly. Methods: Volunteer participants (34) performed a series of tasks typical of patients, such as reading or watching a video, in a full-scale simulated inpatient room. Each participant conducted these tasks under 12 lighting conditions in a counterbalanced order that included varying illuminance levels, correlated color temperatures (CCTs), and in a few conditions, saturated colors. The participants rated each lighting condition on comfort, intensity, appropriateness, and naturalness. Results and Conclusions: The participants found that conditions with CCTs of 5,000 K and higher were significantly less comfortable and less natural than conditions with lower CCTs. Conditions with lighting distributed in multiple zones in the patient room were viewed more favorably than a traditional overbed configuration. The participants in this simulated patient study reacted negatively to colored lighting on the footwall of the room but found a mixture of warmer and cooler luminaire CCTs acceptable.

Background Our objective was to determine if the addition of ultraviolet-C (UV-C) light to daily and discharge patient room cleaning reduces healthcare-associated infection rates of vancomycin-resistant enterococci (VRE) and Clostridioides difficile in immunocompromised adults. Methods We performed a cluster randomized crossover control trial in 4 cancer and 1 solid organ transplant in-patient units at the Johns Hopkins Hospital, Baltimore, Maryland. For study year 1, each unit was randomized to intervention of UV-C light plus standard environmental cleaning or control of standard environmental cleaning, followed by a 5-week washout period. In study year 2, units switched assignments. The outcomes were healthcare-associated rates of VRE or C. difficile. Statistical inference used a two-stage approach recommended for cluster-randomized trials with Results In total, 302 new VRE infections were observed during 45787 at risk patient-days. The incidence in control and intervention groups was 6.68 and 6.52 per 1000 patient-days respectively; the unadjusted incidence rate ratio (IRR) was 0.98 (95% confidence interval [CI], .78 − 1.22; P = .54). There were 84 new C. difficile infections observed during 26118 at risk patient-days. The incidence in control and intervention periods was 2.64 and 3.78 per 1000 patient-days respectively; the unadjusted IRR was 1.43 (95% CI, .93 − 2.21; P = .98). Conclusions When used daily and at post discharge in addition to standard environmental cleaning, UV-C disinfection did not reduce VRE or C. difficile infection rates in cancer and solid organ transplant units.

Nutritional status is a state of health due to interactions between food, the human body and the human environment. If lack of nutrients, the body will be more easily infected. Nevertheless, more nutrition can also be detrimental because it can lead to degenerative diseases. Therefore, it is crucial to maintain a balanced intake of nutrients following the body's needs. This study discusses the description of the nutritional status of schizophrenic patients at the Mental Hospital dr. Soeharto Heerdjan Grogol in 2019. This study used a descriptive observational research method to see the nutritional status and food intake of inpatient schizophrenia patients. One hundred fifty-five schizophrenia patients were hospitalized. The results showed more male patients than female patients. Changes in weight in schizophrenia patients increase more than is reduced. The most nutritional status of schizophrenia patients is good. Patients with malnutrition are 12.9%. Many patients leave

Ribavirin is an inosine monophosphate dehydrogenase inhibitor with demonstrated activity against coronaviruses, including SARS-CoV-2. Five hospitalized patients with COVID-19 (confirmed by positive tests for SARS-CoV-2) received treatment with ribavirin for inhalation solution (ribavirin aerosol) as part of a compassionate use program. Patients included four men and one woman, with an age range of 29–72years. Patients were managed according to international and Italian treatment guidelines for COVID-19. In addition, therapy with ribavirin aerosol 100mg/mL was administered for 30min twice daily for 6days (i.e., 12 doses) in all patients. In order to address concerns about a possible increase in viral dispersal with the use of a nebulizer, healthcare providers remained outside the patient room during ribavirin aerosol administration. Pretreatment chest computed tomography (CT) scans showed pseudonodular areas of parenchymal thickening in the upper right lobe with associated ground glass opacities, multiple areas of parenchymal consolidation in both lower lobes with associated ground glass opacities, bilateral parenchymal thickening and multiple associated ground glass areas, or focal ground glass areas in the upper lobes bilaterally, which were almost completely resolved (three patients) or moderately cleared (one patient) on imaging at the end of ribavirin treatment. For a fifth patient, CT scans showed a stable pulmonary picture at the end of ribavirin treatment. No adverse reactions to ribavirin treatment were observed in any of the five patients. All patients recovered fully, and nasopharyngeal swabs obtained after hospital discharge tested negative for SARS-CoV-2. Ribavirin aerosol appears to be efficacious in the treatment of patients with COVID-19. A controlled trial of ribavirin aerosol is ongoing and will provide additional data across a broader patient population.

Outbreak of COVID-19 in different countries is an emergency in global public health recently. According to high spread of the newborn virus, airborne transmission potency of SARS-CoV-2 is possible. Until now, there are contradictory results for air evaluation of newborn virus in the contaminated area. We studied SARS-CoV-2 in the patient room of a hospital by two air sampling strategies. Filtration method and liquid impaction sampling were used simultaneously to assess SARS-CoV-2 in air. Indoor air of seven stations in three hospital wards was evaluated according to glass midget impinger and polytetrafluoroethylene filter. RNA of SARS-CoV-2 was evaluated by real time reverse transcription-PCR. Studied rooms were contaminated by eleven confirmed patients and four suspected cases. Our results show polytetrafluoroethylene filtration and DMEM impaction could not determine the viral concentration in the air samples. The concentration of SARS-CoV-2 in air samples is a trace in the studied stations. In conclusion, sampling strategy is a challenge for newborn virus due to the level of SARS-CoV-2 virus in the air. A trace level of SARS-CoV-2 in the contaminated area could be highlighted higher pathogenicity properties, not disapproval of airborne properties. However, more studies should be performed to characterize new properties of SARS-CoV-2 in the contaminated air.

Elderly patient falls are expensive and may cause serious harm. Studies have identified the sit-to-stand-and-walk (STSW) task as the task where the greatest number of elderly patient falls occur. There is a great need to identify the particular movement and environmental conditions that lead to these elderly patient falls. This study begins to address this gap by evaluating the elderly patient during self-selected hospital bed egress. Using an observed fall risk episode (FRE) as a fall proxy, statistically significant parameters were identified which include bed height, pausing prior to initiating gait, level of fall risk, and Stand phase. Low bed height was identified as the least safe bed height. Patient-specific bed height (PSBH) using the patient’s lower leg length (LLL) is recommended. In addition, suggested guidelines are presented for clinical application in setting PSBH without measuring the patient’s LLL.

Introduction One of the therapies that Speech and Language Therapy SALT) provide is a level to which fluids must be thickened to ensure a safe swallow. The thickening agent should be supplied by the hospital to the patient on discharge. This requires the thickening agent to be added to the electronic discharge letter (EDL) and, ‘To Take Out’ (TTO) medication list by ward doctors. Method samples of 10-20 EDLs, taken from SALT list of stroke patients between interventions. Cycle 1: SALT were initially attempting to contact the physicians responsible for writing the EDL Cycle 2: SALT kept a register of patients that they had seen the recommended thickener prescription. This list was kept in the doctor’s office. This list was mentioned in handover every morning for doctors to update EDL Cycle 3: The aforementioned list was continued, and responsibility for transfer onto EDLs was delegated to the on call Senior House Officer (SHO) Cycle 4: In addition to the above measures, custom made stickers were added to the prescription chart as an indicator to add thickener to the TTO. Results Cycle 1: 20% Prescribed (n = 10) Cycle 2: 78% Prescribed n = 18) Cycle 3: 93% Prescribed (n = 14) Cycle 4: 100% Prescribed (n = 10). Conclusion This project has built up a multidisciplinary system to a multidisciplinary problem. Through repeated cycles and system improvement, we have seen and demonstrated a collaborative effort resulting in consistent and improving results.

Background The walls across hospital wards are cluttered with posters, which, in some places, are peeling and staining with the years. Hospital management and well intention ward users dictate these displays, however their effectiveness in delivering essential information is rarely measured. We undertook a survey to establish: a) Whether posters are effective, b) What information ward users want, c) How they want information to be delivered. Methods 100 participants (68 staff and 32 patients’ relatives) were surveyed across three 28 bedded wards for older people. They had to recall as many posters as possible then identify useful posters from a current list. They were asked about unmet information needs, other media that they would utilise and alternative uses for ward walls. Interventions were made on one ward based on initial findings: 1. An ‘Information for Relatives’ board was created, 2. A mural was installed. 20 relatives were asked to complete an anonymous form reviewing the board. Results Only 23% of participants were able to recall at least 3 posters. 34% could not find a single useful topic among the current posters. The most popular unmet information needs, among many, were ‘the discharge pathway’, ‘delirium’ and ‘falls’. Most participants said they would engage with alternative information media, suggesting leaflets, email and websites. A quarter felt walls should be for artwork, not posters. The ‘Information for Relatives’ board was well received. In the second survey, new unmet information needs were uncovered and, despite the new mural, 45% called for more paintings still. Conclusions Most people do not read the information on the walls on hospital wards. An appetite exists for alternative media. Paintings were earnestly called for at every point; a comforting ward environment should be part of the holistic care we aim to offer, especially for older patients.

Introduction The acute hospital is a challenging place for a person with dementia whose ability to communicate discomfort and need is impaired. Their discomfort may go unnoticed due to insufficient staffing and time resources in this acute environment. Concerns have been raised about the consequences of these overlooked discomfort (e.g. distress and agitation), and hence how we can correctly identify their sources and severity. This study aimed to describe the source of discomfort and challenging behaviours in people with dementia (PwD) in UK acute hospital. Method A cross-sectional observational study of 49 patients with dementia admitted to a NHS acute hospital. Their discomfort was detected and its sources were identified (Sources of Discomfort Scale) during an hour observation when they were at rest and moved by staff. Their challenging behaviours were also recorded (Neuropsychiatric Inventory) through interviewing with the ward staff, as well as documentation of severity of dementia and presence of delirium. Results The overall prevalence of discomfort was 98%, with excessively sleepy or tired being the commonest; 39 (80%) participants experienced three or more type of discomfort. The commonest sources of discomfort were physical (e.g. constipation) and environmental (e.g. physically restrained), affecting up to 43 (88%) and 42 (83%) participants respectively. There was also evidence of an association between delirium and sleepiness or tiredness’s discomfort, meaning that PwD with delirium were nearly triply as likely to feel uncomfortable because of sleepiness or tiredness. Challenging behaviours affected over 80% of our participants, with agitation or aggression being the commonest. On average, these behaviours were moderately severe. Conclusion Discomfort and challenging behaviours were very common in PwD admitted to acute hospitals. Patients and staff would benefit from more accurate and frequent detection of discomfort by focusing on non-pain-related discomfort and using observational scales.

Introduction During the first surge of COVID-19 it was well recognised that early identification of a plan for escalation in the event of deterioration for each patient was vital. If no decision is documented it results in junior staff frequently making decisions regarding escalation in the out of hours period. This leads to patients, or family members, having these conversations with a doctor they may never have met before. My aim was to improve the documentation of escalation plans in all patients within the first 24 hrs of admission. Method Baseline data was collected in September 2019 with further samples in April 2020 and August 2020. Patient medical notes were reviewed to identify if an escalation plan had been made during the period from admission to post take ward round. A COVID admission pathway document was introduced with a specific section on Clinical Frailty Score and Escalation plan between the baseline and April 2020 data. Results Baseline data showed that only 12.8% of medical patients had a documented escalation plan within the first 24 hrs of admission to hospital. During the first surge in April 2020 this number had improved to 47% following introduction of the COVID-19 admission pathway. This included 100% of patients admitted to respiratory wards. Unfortunately when reassessed in August 2020, this number had fallen to 16%. Conclusion Introduction of clinical frailty scoring and an area specifically to document escalation discussions resulted in a marked improvement. Heightened awareness of rapid deterioration of patients during the first surge almost certainly played a role in this. Unfortunately this was not sustained once staff discontinued the use of COVID-19 admission document. Moving forward we will incorporate these sections into the medical and surgical admissions pathways in the hope it produces similar results.

This study investigates the influence of glazing characteristics and shading device configuration on energy use and cost, daylighting performance and visual comfort. A typical patient room from a h...

The condition of work environment (patient room) is often out of concern to the management so that they do not meet the requirements of Regulation of Minister of Health of the Republic of Indonesia (Permenkes) No. 1204 of 2004 concerning Hospital Environmental Health Requirements. It will have implications for the performance of the doctor (specialist). This study aimed to describe the conditions of the work environment (temperature, lighting, and dust) and the doctor's performance and the relationship between the work environment and the doctor's performance. This research was a quantitative study with a cross sectional design. The research was conducted in 3 teaching hospitals in Medan, namely H. Adam Malik Hospital, dr. Pirngadi and RSU USU during April - November 2018. The study population was 236 people with a sample of 22 people taken using incidental sampling technique. The data obtained by measuring the conditions of the work environment (temperature, lighting, and dust) and interviews using a questionnaire to measure the performance of doctors. Data analysis used Fisher's Exact Test. The results showed that there was no influence of work environment conditions on the doctor's performance, however the temperature and lighting conditions did not meet the requirements. Meanwhile, the temperature of the work room affected the behavior of doctors. Thus, the hospital management needs to take corrective action on working environment conditions by replacing old air conditioners or regularly maintaining air conditioners, setting up a barrier against noise sources, and replacing the bulb with a lighter intensity. The medical committee needs to regularly supervise the work of doctors so that their performance is achieved according to the target.

Research background , Documenting standard nursing diagnoses in Indonesia is very important, however in practice there are still many obstacles that result in incomplete documentation. Nursing diagnosis as a component of Nursing Care Standards needs to be carried out properly as mandated in Law no. 38 of 2014 concerning Nursing in article 30 that in carrying out their duties as nursing care providers, nurses have the authority to determine nursing diagnoses. Research purposes to evaluate the implementation of the standard documentation of Indonesian nursing diagnoses in the Inpatient Hospital of dr. R. Soetijono Blora. Research methods The method used is the Observational Survey with a sample of 60 respondents. The instrument used was a questionnaire for the implementation of documenting standard nursing diagnoses in Indonesia. Research result obtained the implementation of the Indonesian Nursing Diagnosis Standards documentation in the Inpatient Hospital of dr. R. Soetijono Blora was generally good 66.7%, 18.3% very good, and 15% less good. Documentation implementation that needs to be improved includes writing actual nursing diagnoses that must be supported by major and minor signs / symptoms, writing nursing diagnoses of risk and nursing diagnoses that have not been maximized, and writing nursing diagnosis code numbers. Research discussion relating to the implementation of the Indonesian Nursing Diagnosis Standards documentation in dr. R. Soetijono Blora got poor results, one thing that needs to be anticipated is that nurses who do not have sufficient experience need to do training and habituation to carry out the process of enforcing nursing diagnoses systematically. Research conclusions In general, the implementation of the Indonesian Nursing Diagnosis Standards documentation has been carried out well, but it is necessary to carry out training and habituation to carry out the process of enforcing nursing diagnoses systematically

Introduction The Hammersmith and Fulham Community Independence Service (CIS), runs a “virtual ward” to allow people to remain independent in their own homes where possible. Place-of-care decisions made for community-dwelling older people who lack capacity are formulated in a best-interest meeting (BIM), involving health and social care professionals, family and carers. Often BIMs centre around beliefs and wishes of the patient or family but fail to objectively evaluate risks and mitigants of staying at home versus placement. We observed that BIMs were not being held on a consistent basis, and when held lacked the necessary structure for an effective decision-making forum. Even experienced professionals find it difficult to chair BIMs because of the complexity of the decision-making process. Not all involved parties may be represented. We found BIMs more likely to be held, attended and effective when structured to identify the major relevant considerations. Method The CIS “virtual ward” team developed a BIM decision toolkit, comprising: a check-list of risks and mitigants for home versus care home; a list of required attendees; who should document and chair the meeting; and who should action the interventions raised. From 6th January to 25th October 2019, BIMs were held for 48 patients on the CIS “virtual ward”. Results 234 interventions were carried out following toolkit-led BIMs. 1 month after BIM, 34 of 44 patients’ wishes (77%) were honoured (3 not recorded, 1 died). 3 months after BIM, 23 of 31 patients’ wishes (74%) were honoured (15 not recorded, 2 died). Case studies are included in the presentation. Conclusion We developed a toolkit to support decision-making for older community dwellers who lack capacity regarding their place of care. The toolkit assures standardisation and structure to minimise bias, whilst recognising personal beliefs and preferences. It enables any member of the multidisciplinary team to hold and lead a BIM, to reliably identify appropriate interventions and care plans which may not otherwise have been implemented or recognised. The majority of the patients reviewed using the BIM toolkit remained in their preferred place of care well after the team’s interventions. Further evaluation is required to compare CIS BIM toolkit-based outcomes against other community services which do not use this toolkit, and appraise the toolkit in a hospital setting.

Introduction Constipation is exceedingly common on geriatric wards, with 20–50% prevalence. It is associated with complications; including pain, delirium and obstruction. Laxatives, often considered the solution, introduce their own side effects and increase polypharmacy especially in elderly populations. Queen Elizabeth Hospital Birmingham guidelines advocate use of conservative measures, including adequate fluid and fibre intake and increasing exercise, to prevent and treat constipation prior to use of laxatives. However, we had observed that these methods were frequently underutilised, and cause of constipation was rarely considered. We aimed to reduce the prevalence of inpatient constipation and associated complications through the introduction of teaching sessions and multidisciplinary team (MDT) discussions, focusing on staff and patient education on the recognition and conservative managements of constipation. Method We audited notes weekly for the recognition of constipation, appropriate bowel examination, use of conservative management including patient education and any complications. Baseline data was collected from Bournville Ward over 4 weeks (n = 44), after which, teaching sessions for all regular ward staff and weekly MDT discussion for patients recognised as constipated were introduced. Patients having not opened bowels for >2 days were targeted for early simple non-laxative interventions. A further 4-week cycle of data was collected (n = 43). Results Constipation was recognised in 57% of patients studied, of which 64% developed constipation during inpatient stay and 20% experienced associated complications. The introduction of teaching session and MDT reviews increased patient education, cause recognition and non-laxative methods use by 19%, 27% and 30% respectively. Constipation developed during inpatient stay and associated complications decreased by 6% and 4% respectively. Conclusion Despite increased patient education, cause recognition and utilisation of conservative non-laxative approaches, only a small impact was made in reducing inpatient constipation prevalence and associated complications occurring.

Background It is becoming increasingly accepted that discussion and documentation of patient wishes and clinical decisions regarding treatment escalation planning are an essential part of patient care. Following the Tracey judgement, it became a legal requirement, rather than a recommendation, for doctors to involve patients and their families in DNAR decisions. A previous audit in the neurosurgical department found a high prevalence of patients at risk of deterioration with little evidence of attempt to discuss or document treatment escalation decisions (TEDs). Aims Methods We conducted surveys of the multi-disciplinary team within the neurosurgical department to gain a better understanding of their opinions about the current discussion and documentation of TEDs in the department. These contained a mixture of rating scales and free text answers. Following this we engaged senior staff in plans to improve this by introducing these discussions to governance meetings and educated all members of the ward using e learning and tea trolley teaching. Results Amongst 18 healthcare professionals, 12 felt patients did not have clear TEDs. Ten felt discussions were not appropriately timed. Response themes included feeling unsupported, poor timing of conversations and low quality documentation. Following this a consensus decision from the consultant body mandated documentation of TEDs in patients presenting with chronic subdural haematomas. We have worked closely with the national ReSPECT programme and established the neurosurgical ward as a lead for the introduction of the new form. Conclusion The neurosurgery department is now at the forefront of the move to improving discussions and documentation about patient wishes in the Trust. Additionally, we have opened the conversation within the multi-disciplinary team and provided training and education about the importance of TEDs.

Introduction An estimated 64 million Medication Compliance Aids (MCAs) are dispensed by pharmacies in England each year as a method of reasonable adjustment to improve medication adherence (NICE 2009) and support medicines administration by carers (RPS 2013). Complexities exist when implementing medication changes for patients using MCAs, particularly at hospital discharge or outpatient appointments, where practices seem to vary. This National Survey is the first to determine the current policy and service provision of MCAs by acute hospitals in England. Methods An electronic survey was emailed to Chief Pharmacists via the Regional Medicines Information Services in Spring 2019. Initial non-responders were contacted by email and telephone. Results 51% (73/144) of acute hospital trusts in England responded. 77% (56/73) dispensed medication in MCAs at discharge. Of these, 62.5% would initiate MCAs and 61% supplied a different length of MCA vs non-MCA prescription (see table). 41 hospitals had designated staff completing MCAs. The median time to complete an MCA was 59.5 minutes (range 10–200). The median time from prescription receipt in pharmacy to MCA arrival on ward was 144.5 minutes (range 60–1,440). Of the 17 hospitals not providing MCAs, the majority would, upon discharge, contact the community pharmacy that provided the MCA pre-admission to update any medication changes and request the provision of a new supply of medicines. Conclusion Despite the ubiquitous nature of the MCA, there is no standard approach to the supply of these devices from acute hospitals across England. When hospitals do provide MCAs their preparation is time consuming, often requiring additional staff. A national approach to MCAs might help patients and carers, and reduce medication-related problems and costs.

Background This quality improvement project aims to improve communication between secondary and primary care at the time of hospital discharge of older patients. Introduction Discharge summaries (DS) are a key component of communication between secondary and primary care. Poor quality DS are associated with poorer outcomes in terms of adverse events [1], readmissions [2] and medication errors [3]. There is NICE and AMRC guidance on what constitutes a good DS [4, 5]. Method Prospective review of DS from a range of wards was completed in August 2017 against a detailed data tool. A random selection of DS from the same wards was audited monthly from November 2017 onwards. A novel live-feedback system was introduced to the same wards in February 2018 so that the teams completing DS received feedback on how well their summaries complied with the recommendations and what areas needed improvement. A change in staffing lead to a break in the delivery of monthly feedback to the ward teams from April to September 2019 when it was re-commenced. Results In the majority of areas there has been an increase in the quality of the DS from the beginning of the project until March 2019 when the regular feedback interventions were suspended. There was a decrease in the quality of summaries in July and August 2019, followed by an increase as regular feedback interventions recommenced in September 2019. The aggregate results of the four main components of DS (follow-up actions, medicines, clinical summary, and functional assessment), scored “good” in 13% of DS at baseline, 40% in March 2019, 20% in July 2019 and 31% in October 2019. Conclusions The suspension of regular direct interventions resulted in a significant deterioration in the quality of discharge summaries, and this improved quickly after reintroduction of PDSA cycles in key areas. Continuous quality improvement requires uninterrupted focus on regular live feedback. References 1. Clegg et al. Lancet 2013; 381: 752–62. 2. Samra et al. Age Ageing 2017; 46: 911–9. 3. Romero-Ortuno et al. Age Ageing 2012; 41: 684–9.

Intro In July 2019 the MHRA issued a drug safety update reminding healthcare professionals that rivaroxaban should be taken with food. This came after they received a number of thromboembolic events reported in patients prescribed rivaroxaban, thought to be linked with incorrect ingestion on an empty stomach [1]. Our aim was to establish if the healthcare professionals in our department had this knowledge and to audit our current dispensing practice to assess if our hospitalised patient cohort were being exposed to any increased risk. Methods A retrospective study was conducted using electronic data from 21 patients that were prescribed rivaroxaban across 14 medical wards. A questionnaire was used to establish the staff’s knowledge. Results Of the surveyed healthcare professionals, 79% knew that rivaroxaban should be taken with food (86% of nurses and 79% of doctors). Despite this only 17% of patients took the tablet with food. 75% of patients had rivaroxaban incorrectly dispensed over an hour post meal and 8% were uncertain due to poor documentation. Only 14% of healthcare professionals were aware that in those with swallowing difficulties, rivaroxaban can be crushed. Conclusions In our department most of the healthcare professionals had a good academic knowledge of correct rivaroxaban administration, however we have demonstrated that this is failing to correctly influence clinical practice. 75% of patients taking Rivaroxaban in hospital are being subjected to increased risk due to the hospital environment. This was found to relate to the difference in timing of the drug dispensing round in comparison to meal times. As part of the roll out of electronic prescribing in our trust, a warning now shows when both prescribing and dispensing Rivaroxaban to attempt to improve this highlighted risk. We have also highlighted this to the ward managers and at our governance meeting. Reference 1. Drug Safety Update volume 12, issue 12: July 2019: 3.

Introduction Numerous frailty tools and definitions have been described. Amongst hospitalised patients, the validity of face-to-face instruments may be confounded by acute illness. However, patient assessment after recovery at the point of hospital discharge, or recognition of electronic health record (EHR) frailty markers, may overcome this issuep. Methods In a consented, prospective observational cohort study, we recruited patients ≥70 years old within 24 hours of expected discharge from the cardiology ward of the Royal Infirmary of Edinburgh. Three established frailty instruments were tested: the Fried phenotype, Short Physical Performance Battery and nurse-administered Clinical Frailty Scale (CFS). An unweighted 32-item EHR score was generated using frailty markers (e.g. falls risk, continence, cognition) recorded within mandated admission documentation. Comorbidity was assessed by count of chronic health conditions. Outcomes were a 90-day composite of unplanned readmission or death and 12-month mortality. Adjusted Cox modelling determined the hazard ratio (HR) per standard deviation increase in each frailty score. Results 186 patients (mean age 79 ± 6 years, 64% male) were included, of whom 55 (30%) had a 90-day composite outcome, and 21 (11%) died within 12 months. All four frailty tools were moderately correlated with age and comorbidity (Pearson’s r 0.21 to 0.43, all p 0.05) once frailty was included in modelling. Conclusions At hospital discharge, the Fried phenotype and CFS added to age and comorbidity in risk prediction for future unplanned readmission or death. EHR frailty markers appeared comparable to face-to-face assessment. An automated trigger for high-risk patients using routine EHR data merits prospective evaluation.

Introduction Acute hospitalisation is associated with an increased risk of progressive frailty, morbidity and subsequent institutionalisation. North Middlesex University Hospital is an Acute District General Hospital with over 550 attendances to A&E per day. Comprehensive Geriatric Assessment (CGA) is the gold standard approach for a holistic multi-disciplinary assessment (MDT) of frail patients. A rapid access daily hot clinic service for frail patients opened using quality improvement (QI) methodology to deliver rapid CGA focusing on admission avoidance and early supported discharge. Method 4 PDSA cycles were conducted. A process map identifying key moments in patient care was derived from time studies of the first 10 patients’ journeys. Patients were triaged through the Geriatrician “hotphone” for acute admissions into the Hot Clinic. Dedicated clinic and waiting rooms were placed on the acute frailty unit (Amber) staffed by a dedicated Consultant Geriatrician and Health Care Support Worker working with the Frailty Ward Clerk, Frailty Specialist Nurse, Therapies, specialities in-reach and same-day diagnostics. A shared clerking proforma and subsequent CGA Discharge Summary were completed and emailed to the referrer the same day. Qualitative and Quantitative feedback was gained from referrers, patients and relatives through a structured questionnaire. Metrics were gathered including rate of admissions, re-attendance and use of enhanced community services. Results From the first 48 Hot Clinic patients, there was a low 30-day re-attendance rate (17%—for unrelated reasons), low 30-day re-admission rates (4%) and low Did Not Attend rate (6%) for new referrals and high satisfaction scores for recommending the service (9-10/10) from patients, relatives and referrers. Conclusions Early rapid MDT can reduce re-attendances and re-admissions to hospital in frail patients. A streamlined patient journey can be delivered by frailty-trained staff and in a suitable environment. QI Methodology enables a structured measurable approach to development of the Acute Frailty Pathway.

Introduction NICE and the National Osteoporosis Guidance Group (NOGG) advise on evaluation of fracture risk and osteoporosis treatment1,2, with evidence suggesting that screening and treatment reduces the risk of fragility fractures 3,4,5. However, it is often overlooked in the management of older patients within secondary care. Audit data from Sheffield Frailty Unit (SFU) in 2018 showed that national guidance was not routinely followed. Fracture Risk Assessment Tool (FRAX®) scores were not calculated and bone health was poorly managed. Therefore, we undertook a quality improvement project aiming to optimise bone health in patients presenting to SFU. Method & Intervention In January 2019 we collaborated with Sheffield Metabolic Bone Centre (MBC) to develop a pathway aiming to improve bone health assessment and management in patients presenting to SFU with a fall or fragility fracture. This included a user-friendly flow chart with accompanying guidelines, alongside education for staff. Performance was re-evaluated in May 2019, following which a tick box prompt was added to post take ward round documentation. A re-audit was performed in March 2020. Results In March 2018 0% of patients presenting with a fall had a FRAX® score calculated and only 40% of those with a new fragility fracture were managed according to guidelines. In May 2019, this had improved to 18% and 100% respectively. In March 2020 86% of patients had a FRAX® score calculated appropriately and 100% of fragility fractures were managed according to guidelines. In both re-audits 100% of FRAX® scores were acted on appropriately. Conclusions There has been a significant increase in the number of patients who have their bone health appropriately assessed and managed after presenting to SFU. However, achieving optimum care is under constant review with the aim to deliver more treatment on SFU, thereby reducing the need for repeat visits to the MBC.

Introduction Quality person-centred care in those approaching the end of life includes consideration and anticipation of their preferred place of death and ceiling of care (CoC). This QI project to reduce inappropriate readmissions was prompted following the transfer of a palliative patient to the acute trust from a community hospital. Method Data was collected from the electronic patient record (EPR) at weekly intervals over a six month period, July to December. Electronic documentation of CoC from 507 records from a 24 bed community hospital was reviewed. Data collected included patient age, sex and whether a CoC decision entry had been made on the EPR during the community hospital inpatient stay. The appropriateness of readmissions over the same period was also analy sed. A weekly consultant geriatrician ward round was introduced focusing on advanced care planning with explicit decision making regarding preferred place of care. Results There were a total of 16 readmissions during the study period. 3 of these were deemed “inappropriate” following EPR review occurring in August, September and October. Subsequent review of electronic CoC July to October inclusive demonstrated a median completion rate of 20.5%. Following intervention there were no further inappropriate readmissions and the median CoC completion rate was 85%. Qualitatively, the consultant geriatrician managing the community hospital felt there had been a cultural shift where staff felt more comfortable managing complex palliative care. Conclusions Introduction of a weekly Consultant Geriatrician ward round in the community setting has led to a sustained improvement in CoC decision-making and documentation. As a result of this there have been no further inappropriate readmissions to the acute trust. This reflects the national guidance in patient centred palliative care. Further work including robust, qualitative assessment of staff attitude towards palliative care is needed to emulate this work at other local community hospitals.

Background Acute kidney injury (AKI) in hip fracture patients is associated with morbidity, mortality, and increased length of stay. To avoid this our unit policy recommends maintenance crystalloid IV fluids of >62.5 mL/Hr for hip fracture patients. However, audits have shown that many patients still receive inadequate IV fluids. Methods Three prospective audits, each including 100 consecutive acute hip fracture patients aged >55, were completed with interventional measures employed between each cycle. Data collection points included details of IV fluid administration and pre/post-operative presence of AKI. Interventions between cycles included a revised checklist for admissions with a structured ward round tool for post-take ward round and various educational measures for Emergency Department, nursing and admitting team staff with dissemination of infographic posters, respectively. Results Cycle 1: 64/100 (64%) patients received adequate fluids. No significant difference in developing AKI post operatively was seen in patients given adequate fluids (2/64, 3.1%) compared to inadequate fluids (4/36, 11.1%; p = 0.107). More patients with pre-operative AKI demonstrated resolution of AKI with appropriate fluid prescription (5/6, 83.3%, vs 0/4, 0%, p Discussion This audit demonstrates the importance of administering appropriate IV fluid in hip fracture patients to avoid AKI. Improving coordination with Emergency Department and ward nursing/medical ward staff was a critical step in improving our unit’s adherence to policy.

Background This quality improvement project was based at The Royal Bolton Hospital across our four Complex Care wards. Introduction We have recently transferred to electronic record keeping. At these points of transition there may be an adverse impact on the quality of patient care and safety. We recognised on our own ward there were inaccuracies between the required paper form and electronic documentation of DNACPR decisions. Consequently, we wanted to review and improve the accuracy of our DNACPR documentation to ensure safe and effective patient care. Methods To gauge the scope of the problem we audited 87 patient’s electronic and paper notes, with no exclusion criteria. We reviewed whether each patient had a formal resuscitation decision, and if a DNACPR decision had been made whether we met our hospital policy by having: 93% of the 87 patient’s had an active decision regarding resuscitation, with a DNACPR decision documented for 50 patients. Of these 50 patients only 11 had all three forms of documentation. More worryingly, there were discrepancies in the documented DNACPR decisions for 11 patients across paper and electronic records. Interventions We escalated our concerns to the Clinical Governance team who sent out a trust wide SBAR highlighting this as an urgent clinical issue. On a directorate level we incorporated DNACPR decision documentation into our afternoon safety huddle and arranged informal teaching for medical, nursing and administrative staff. Results Reassuringly, the subsequent re-audit of 90 patient’s notes showed only one patient to have a discrepancy between paper and electronic documentation. We saw an improvement to 98% having paper forms in the right bedside notes and 100% having a documented electronic DNACPR decision. Conclusion Through local education and trust-wide dissemination of our expected standards we have seen some improvement. We recognise the importance of maintaining this, and importantly that there is still work to be done. The electronic “Resuscitation and treatment escalation plan” is still rarely completed and provides important information on escalation of care and thus will be the focus of a further educational intervention.

Introduction On the surface discharging a patient seems a simple a simple process, but delays due to coordination and communication in preparing medication, transport and discharge summaries are all to common. This results in delayed discharge, which is unfair on patients and their families, adds to the risk of hospital acquired infection and increases NHS expenditure and bed pressures. This quality improvement project investigates alternate systems for coordinating this process to make it more efficient and easier for the relevant stakeholders, with the added advantage of being “bleep free” as is the Health Secretary’s target for 2021. Method We started with process mapping and summarising the challenges faced by stakeholders in the current system, which uses bleeps for communication across six older people medical wards and ten medical teams. We progressed to iterative PDSA cycles using Medxnote for one medical team across all wards and then Microsoft Teams on one ward with ten medical teams. New process maps for each were created and circulated to stakeholders to explain the roles and responsibilities of each team. Results Both Medxnote and Microsoft teams subjectively made communication easier. However, Medxnote was hampered by the inability to have a three-person conversation and the required use of personal phones. Microsoft teams overcame these obstacles and was able to demonstrate objective improvements with a 42% increase in medication screened before 1 pm and 72% increase in medications prepared on the day of discharge, suggesting better prioritisation. Team feedback was that it decreased workload, made team members more accessible and minimised interruptions to working day. Conclusions The initial PDSA cycle suggests Microsoft teams is a promising tool for improving the discharge process and aiding bleep free communication amongst members of the multidisciplinary team. The next step will be a trial across all wards with all teams.

This study aimed to better understand appropriate interventions aimed at reducing hospital ward noise and the subsequent impact this would have on inpatient experience. Service users consistently reported that noise pollution was the most detrimental factor in their recovery in hospital, principally due to its effects on sleep. Methods To aid usability and data collection the Richards- Campbell Sleep Questionnaire (RCSQ) was adapted into an electronic format with a sliding Likert scale using QuestionPro Software3. Qualitative patient interviews, the RCSQ and ward decibel measurements were recorded on Henry and Anne wards at St. Thomas’ Hospital, London. 20 patients were interviewed (12F, 8 M), with 3 being ultimately discounted due to severe cognitive impairment. Results were collated and will be presented as part of a pre-feasibility evaluation of the tools to measure patient sleep and experience of ward noise. Results: The mean of the responses from the 17 patients interviewed were calculated and graphically displayed. Of interest, 87.5% found the questionnaire straightforward to understand, but only 18.75% found it easy to complete (due to technological unfamiliarity). Conclusion and discussion Patients reported a consistently reported a less than optimal night’s sleep on the ward, with light sleep and increased time to fall asleep being key factors. Although visits were restricted to the “quietest” times on the ward, noise measurements consistently exceeded WHO recommendations of 40 dB. Subsequently excessive night-time noise created by other patients as well as staff was cited as the principal causes of poor sleep, with ward lighting being another cause. Results from this study have provided the justification for sound-masking technology to be trialled on inpatient wards, with the view of decreasing unpleasant ward noise and improving patient rest and recovery.

Introduction Surrey Downs Health and Care (SDHC) is an innovative partnership consisting of the acute trust, community provider, three local GP federations and local authority. Together they deliver integrated health and care services for the Surrey Downs population. In April 2019, SDHC formally took over the management of an acute escalation ward at Epsom General Hospital. The aim was to redesign the model of care to offer a more integrated approach towards the management of patients with frailty. Method A change in leadership with interface frailty consultants developing an integrated multidisciplinary team (MDT) with reassignment of community staff. All members of the MDT had an equal voice and this helped develop the one team ethos. There were many developments along the way, but key changes included the agreement that a patients’ time is the most valuable currency and that we should be changing conversations from “what is the matter with you?” to “what matters most to you?” Results 1. A 100% increase in average daily discharges 2. An increase to 70% being discharged to their own home, versus 20% previously 3. A reduction from an average length of stay of 40 days to 13 days compared to the same time last year 4. Reduced 30-day readmissions at 15% versus previous average of 25%. Conclusion By blurring boundaries between the acute and community, allowed a frictionless pathway for patients. This has led to improvement in patient care and outcomes for the patient and system as a whole.

Topic At Barnsley Hospital we targeted an improvement in the care of frail patients. The first objective was to improve the patient journey by reducing the amount of time that frail patients spend in busy acute environments. The second objective was to deliver more effective Comprehensive Geriatric Assessment which is recognised as gold standard management (Ellis, G. BMJ 2011;343:d6553). Intervention A new frailty chaired area was opened in July 2018 with capacity to receive up to 6 patients per day from acute admission areas and aim for same day discharge. We developed our own bespoke criteria to ensure that suitable ambulatory patients were identified to access this new pathway. This was called “FACT” Criteria- Frail, Ambulatory, Clinically stable, Time to call. Patients received an MDT model of care which was documented using a newly developed electronic tool called electronic Comprehensive Geriatric Assessment (eCGA). Improvement To evaluate the patient journey we measured the average time between the Acute Medical Unit (AMU) Post Take Ward Round (PTWR) and onward move. Comparison was made between the 2 month periods July—August and November—December 2018. This demonstrated that the average time reduced from 10.3 to 5.1 hours. Between July 2018 and April 2019 a total of 689 patients were assessed in the frailty chaired area of which 60.8% were discharged from the hospital the same day. Discussion The patient journey for frail ambulatory patients now involves significantly less time on AMU awaiting onward move. Comprehensive Geriatric Assessment is delivered more effectively and documented electronically using eCGA. This tool promotes better information sharing and has a specific section for advance care planning. This new pathway has a high same day discharge rate of 60.8% which reduces length of stay for our frail patients.

Introduction Delirium is a common condition that is often associated with increased morbidity and mortality, longer hospital admission, and discharge to a residential or nursing home. By improving our ability to recognise and manage these patients we can intervene early to help reduce the likelihood of these outcomes. Method We organised several in-situ simulation scenarios with junior staff working on the Elderly Care Unit. The research team designed a scenario to re-create a typical delirious patient on the ward. Participants had to recognise the patient was delirious and instigate a management plan. Participants completed a pre and post-intervention questionnaire to ascertain whether they felt the simulation had improved their confidence. Additionally we performed an audit to investigate whether our intervention led to an improvement in the recognition and management of delirium in patients on the ward. Results The questionnaires showed an increase in participants’ confidence and knowledge when managing a delirious patient on the ward. From reviewing patient notes pre-intervention we identified that 24 patients were delirious during admission,14 of which were accurately diagnosed with delirium. The remaining 10 patients were diagnosed with “Acute Confusion”. On reviewing these 10 patients’ notes, they were all likely to have a diagnosis of delirium. Post-intervention there were 14 patients identified as delirious during their admission. All these patients were correctly documented as having delirium with no inaccurate use of terminology. The data also showed increasing use of tools such as AMTS and 4AT to diagnose delirium. Conclusions From the data gathered, we can see participants are better at recognising and diagnosing delirium. However, our sample sizes are too small to test statistical significance between data points. To improve the project we would include a larger sample size to determine whether the simulation produces a statistically significant improvement in confidence levels.

Our project was conducted in a district general hospital across five acute geriatric wards. Our team included consultants, registrars, and ward matrons. The project focused on improvement of care for geriatric inpatients, with moderate to severe frailty. Advanced care planning (ACP) columns are displayed on white boards. They indicate whether ACPs are required/initiated for each patient. When previously utilised, ACPs were initiated for 78% of appropriate patients [1]. Following a change in staff and reduction in awareness/education, the ACP column use reduced with fewer ACPs established. Our goals were to ensure completion of the ACP column, encourage junior doctor/nurse involvement and trigger a greater number of appropriate ACPs initiated Improvement in ACP practice was addressed by daily board round review of appropriate patients for ACP, increasing awareness of ACP triggers and education around discussion content. Interventions consisted of: 1, a flow-chart adjacent to white boards prompting “Do not attempt resuscitation (DNAR)” and ACP processes. This signposted staff to information on ACP triggers and “how to start a conversation”. 2 Involving registrar “champions” on each ward. We explained our intervention to all team members to encourage engagement. Data from the ACP columns were audited prior to intervention, 2 weeks and 6 weeks after intervention. There was a 54% increase in ACP documentation after 6 weeks across the wards. The improvement in the use of the ACP column correlated with a greater number of ACPs initiated. This facilitated an increase in consideration of patient wishes towards the end of life. Increasing use of a daily ACP prompts on board rounds triggers an increase in ACP implementation for appropriate patients. Sustainability was achieved by recruitment of ward “ACP champions”. Junior doctors/matrons were more empowered to discuss ACPs. Results were presented at departmental teaching to reinforce the positive impact of the intervention.

Background The Royal College of Physician guidelines (2011) identified handover as a “high risk step” in patient care, especially in recent times within the NHS where shift patterns lead to more disjointed care with a high reliance on effective handover by all staff members. Introduction At Cannock Chase hospital, Fairoak ward is an elderly care rehabilitation ward where there is a large multi-disciplinary team. While working on the ward as doctors we noticed that handover between the MDT was poor. Anecdotal evidence from both doctors and nurses felt that this was a high risk area in need of improvement. Aim to improve handover between doctors and nurses on this elderly care ward. Method To measure the quality of current handover practice we did a questionnaire. A total of 12 questionnaires were completed which showed that 92% of staff felt that handover on the ward was very poor and 50% preferred both written and verbal handover. We measured the number of tasks verbally handed over between doctors and nurses over 3 days. On average 65% of the tasks were completed. We then made the below interventions and re-audited to see if there was any improvement. Interventions over 3 week period: Results Questionnaire: Measuring task completion after interventions; Conclusion This project has made a positive change qualitatively and quantitatively to the ward handover practice. Staff satisfaction regarding handover has improved and the number of “handed over” tasks completed daily has significantly improved. The written handover sheet had poor utilisation by staff but in 4 months we are going to re-audit and trial the handover sheet again to further improve service delivery. We hope this improvement will have a positive impact on patient care on this elderly care ward.

Introduction In September 2017 our frailty service was started within our medium sized DGH in North Wales. Working with our management team we secured a significant clinical resource including: We describe how resources, setting and staffing develop over a 2 year period in order to create a service which meets the needs of the local population. Method The service has been in a constant state of development since it has been in operation, utilising a PDSA model with regular meetings of clinical and managerial staff to analyse performance. Results With each new PDSA cycle the amount of patients reviewed has increased. With the move to AMU we increased the monthly number of patients reviewed from 29 to 172 patients reviewed, 97 of which were discharged directly from the unit. Conclusion Using QI methodology our Frailty Service has improved dramatically since its inception. We will continue to analyse how we work to improve patient outcomes and cost effectiveness.

Introduction Fluid balance charts are frequently incomplete and inaccurate. At present our Trust does not offer fluid balance training to all ward staff. In addition, drinks given to patients by visitors are not usually documented on the fluid balance charts. The goals of this quality improvement project were therefore to: Methods Using the PDSA model a questionnaire was given to ward staff as a scoping exercise to identify the deficiencies in fluid balance education prior to the intervention and fluid balance charts were analyzed. The intervention involved: Results Pre-intervention questionnaires demonstrated that 31% of staff asked were not clear on the meaning of fluid balance and 88% felt that more fluid balance awareness was needed on the ward. In addition, 7/8 randomly selected fluid balance charts were incorrectly completed. Post intervention 87% understood the meaning of “fluid balance” monitoring and 7/8 fluid balance charts were correctly completed. Conclusion The intervention educated all ward staff and improved the accuracy of fluid balance monitoring. It also provided information and guidance to non-medical staff and visitors regarding fluid balance monitoring. Following the success of the project the intervention is being rolled out across the Trust alongside education sessions for staff.

Background To improve delirium care in older patients admitted to a large district general NHS Trust in the UK, a quality improvement project was conducted. Introduction The national NICE guidelines (CG103) and recent SIGN guidelines recommend delirium is diagnosed by a clinical assessment based on DSM criteria (e.g. CAM or 4AT) and managed by identifying and treating the causes alongside multicomponent interventions. The results of MYHT’s 2018 delirium audit showed the use of CAM or 4AT was 32.5% and delirium care plan was 20%. A quality improvement project was developed and implemented for 6 weeks on a frailty admission unit. Method The quality improvement project introduced a delirium care checklist sticker for medical notes in cases of suspected delirium, brief education sessions for ward doctors regarding delirium care and use of the sticker and reminder emails, all implemented by the elderly medicine registrar. The target measures were completion of stickers, 4AT and delirium care plan. Data was collected by the registrar once a week for 6 weeks and entered into a run chart. Feedback was collected from staff on barriers to use. Results 31 patients with suspected delirium has their notes reviewed. The sticker use gradually reduced from 57% of cases in week 1, to 0% in week 6. The 4ATwas completed in 57%, 50% and 100% of cases in the first 3 weeks, but dropped to 40%, 4.2% and 1.3% in the last 3 weeks. A delirium care plan was initiated in 42% and 37% of cases in the first two weeks but ended at 0% by week 6. Barriers included a lack of education sessions from week 2 onwards due to registrar on call shifts. Also junior doctor changeover in week 3. Feedback indicated barriers were time taken to complete, and confusion over ownership of completing 4AT and care plan between medical and nursing teams. Conclusion Although a delirium care checklist sticker and brief education sessions can improve delirium care, sustained improvement requires ongoing education and addressing barriers to completion. References 1. National Institute for Health and Care Excellence (2019) Delirium: prevention, diagnosis and management (NICE Guideline CG103). Available at: https://www.nice.org.uk/guidance/cg103 Accessed 21/09/2019]. 2. Scottish Intercollegiate Guidelines Network (2019) risk reduction and management of delirium (SIGN Guideline 157). Available at https://www.sign.ac.uk/assets/sign157.pdf. Accessed 21/09/2019.

Topic Early recognition and multidisciplinary management of frail patients in acute care is a national priority. This is reflected in the NHS 10 year plan, NHS Improvement (NHSI) and Getting It Right First Time (GIRFT) ambitions for acute care. The Sunderland Royal Hospital acute frailty service currently reviews frail patients on the Medical Admissions Unit (MAU) each morning. Analysis of our emergency department (ED) data demonstrates that most frail patients arrive to the ED between 12 pm and 18 pm leading to a cohort of frail patients who are not receiving comprehensive geriatric assessment early in their patient journey. Here, we present our piloted expansion of the frailty service into the ED. Intervention Currently the frailty service is provided on MAU between 9 am and 1 pm. The pilot service expansion ran for five weeks between September and October 2018 and involved the acute frailty team being available to ED and MAU from Monday to Friday 0830 am to 1700 pm. Frail patients were proactively identified using the ED patient tracker as well being referred to the team by ED staff. Improvement During the pilot, the team reviewed 131 additional patients. 85% were seen in ED. 61 patients were discharged directly from ED and 33 patients were admitted directly to a back of house medical ward resulting in reduced MAU occupancy rates in the evenings. Concerns that bringing full MDT assessment into ED might result in increased time spent in ED were proven to be unfounded. Median length of stay for admitted patients was low with 49% discharged within 7 days and 9.9% 30 day readmission rate. Feedback from ED and community teams was positive. Discussion It is recognised that early CGA is beneficial for patients with frailty syndromes who are admitted to hospital. Most commonly, this takes place on medical admissions wards. Through this pilot, we have demonstrated significant added benefits of bringing the acute frailty team and crucially CGA into the emergency department setting. As well as increased discharges directly from ED, we demonstrated a reduction in length of stay and readmissions as well as improved patient flow. Our aim is to permanently implement a seven day frailty service with input on MAU as well as ED.

Introduction With our ageing population there is increasing number of patients who experience a decline in their mobility either because of their underlying diagnosis or as a consequence of their hospital stay. There are only a limited number of inpatient rehabilitation beds and it is therefore important to identify those that would benefit the most from inpatient rehabilitation. Method We undertook a retrospective study looking at three months of discharges from an inpatient rehabilitation ward in Manchester. Patients were categorised based on diagnosis (Pubic rami fracture, other fractures, fall with no bony injury and finally medical reasons) and Clinical Frailty Score to see if either had any effect on whether patients mobility improved and to what degree. Results Patients with a reduced mobility on admission were identified and then categorised based on diagnosis. Of those patients admitted with a pubic rami fracture 66.7% improved on the ward with 33.3% of patients reaching their baseline mobility. The mobility of 85.7% of patients with other fractures improved with 42.9% reaching their baseline. Patients admitted following a fall without bony injury showed, 75% improvement with 50% reaching their baseline. Of those admitted for medical reasons 88.9% of those improved but only 22.2% reaching their baseline mobility. The lowest proportion of any category. Those admitted for medical reasons also had the longest median average stay on the rehab ward (33.5 days) followed by other fractures (33 days) then fall with no bony injury (21.5 days) and finally the shortest average stay, pubic rami fractures (20 days). Patients were also grouped occurring to their preadmission Clinical Frailty Score. With the exception of those who scored four (only a small number of patients), there was a negative correlation between an increasing frailty score and the proportion of patients whose mobility improved. However as frailty score increased the proportion of patients who improved to their baseline increased. Conclusion Our study has shown that the majority of patients benefitted from their admission regardless of diagnosis, however those admitted for medical reasons had the lowest chance of reaching their baseline mobility despite the longest admissions on the ward. Further research may be beneficial to investigate if they do better in a different rehabilitation setting.

Introduction NICE guidelines state that urinary catheter insertion, changes and care should be documented. Duration of catheterization is directly linked to the risk of developing a catheter-associated UTI. Furthermore, Public Health England has announced a national aim to reduce the incidence of Gram-negative bacteraemia by 50% by March 2021, and targeting catheters is one of the first steps. Local problem These issues are relevant to the elderly population at Princess Royal University Hospital, where documentation surrounding catheters was found to be inadequate. Despite there being an Electronic Patient Record (EPR) order for catheter insertion and monitoring available, this was not being used. Our primary aim was for all patients to have this order. We also hoped to reduce the weekly rate of catheter days (catheter days per 100 bed days), and improve documentation in clinical notes. Methods We focused on two medical wards and sampled all patients admitted over a period of 4 months who had a catheter at the time of data collection. We identified catheterized patients and whether they had an EPR catheter order on a daily basis. Additional parameters such as indication, insertion date, inserter, and documentation standards were extracted from EPR on a weekly basis. Patients were kept “live” and contributing to catheter day calculations until they were no longer on the ward or if the catheter was removed. Interventions We implemented changes over 2 PDSA cycles. Interventions included the addition of catheter columns to boards and education sessions for doctors and nurses (cycle 1), as well as catheter posters, alert cards, and circulation of emails with guidance to doctors and nursing staff (cycle 2). Results A total of 87 patients were analysed during the project. There was an increase in EPR orders being used, with the 100% target being reached on the final data collection point, and with data showing a significant shift above baseline. Furthermore, there was a decrease in the weekly rate of catheter days, but changes were difficult to sustain. We also saw a general improvement in documentation standards. Conclusion By improving documentation and reducing unnecessary catheterization, we hope to have reduced the overall risk of infection whilst improving patient comfort and experience. Lessons may be transferrable to other trusts.

The development of increasingly sophisticated medical science and technology has an impact on the development of science and technology in the field of medical-devices. One of the existing equipment and is often used in hospitals, one of which is an IV. Currently in the world of health, infusion is still controlled manually. Because it takes time if the nurse has to go back and forth throughout the patient room. Not only is it time consuming, but there will be risks if it is too late to treat a patient whose infusion has run out. Technology needs to be used to minimize risks in the medical world, one of which is the application of IoT technology. This study aims to make it easier for nurses to control infusion conditions in real time using the concept of IoT ( the Internet of Things). The method used is the Waterfall method. This research uses hardware consisting of Load Cell with the HX711 module as a weight sensor, NodeMCU V3 as a processor, and Thingspeak Web server as the interface with the user. The results of the measurement of the tool made have an error of 0.25 Gram, sending data to the Thingspeak.com Server requires a good connection for maximum results.

With increasing demands on medical care services, one of the trends is the mixed patient room arrangement of single/double-bed and multi-bed rooms in a nursing unit on the same floor. This influences nurse-to-patient assignment and often causes an unbalanced workload and longer travel distances for nurses. The objective of this study was to investigate how floor configuration and room density influence nurse travel in the hospital's medical surgical units in Korea. This study presented a novel approach to measure nurse travel distances in eight existing nursing units. The agent-based simulation was conducted to model nurses' walking trails, and the distance of one nurse travel to assigned patient rooms was measured for each nurse. With revisions in the spatial arrangement of patient rooms, locating multi-bed rooms near the nurse station, symmetric room layout centering the nurse station, and planning both single/double-bed and multi-bed rooms on one side of corridors, nurse travel distance decreased more than 15%. This study contributed to the knowledge of agent-based simulation as an evaluation framework for spatial analysis. Apart from application to Korea, these results are particularly of interest in countries where private patient rooms are not commonly economically feasible.

Background In prevention, sedentary behaviour and physical activity have been associated with risk of cardiovascular disease and mortality. Less is known about associations with utilization of hospital care. Aim To investigate whether physical activity level and sedentary behaviour prior to cardiac ward admission can predict utilization of hospital care and mortality among patients with cardiovascular disease. Methods Longitudinal observational study including 1148 patients admitted and treated in cardiac wards in two hospitals. Subjective reports of physical activity levels and sedentary time prior to admission were collected during inpatient care and categorized as low, medium or high. The associations between physical activity level and sedentary time with hospital stay, readmission and mortality were analysed using linear, logistic and Cox regressions. Results Median hospital stay was 2.1 days. One higher step in the physical activity level, or lower sedentary time, was related to an approximately 0.9 days shorter hospital stay. Sixty per cent of patients were readmitted to hospital. The risk of being readmitted was lower for individuals reporting high physical activity and low sedentary time (odds ratios ranging between 0.44 and 0.91). A total of 200 deaths occurred during the study. Mortality was lower among those with high and medium physical activity levels and low sedentary time (hazard ratios ranging between 0.36 and 0.90). Conclusion Both physical activity level and sedentary time during the period preceding hospitalization for cardiac events were predictors of hospital utilization and mortality. This highlights the prognostic value of assessing patients’ physical activity and sedentary behaviour.

Purpose: This study explores how aspects of lighting in patient rooms are experienced and evaluated by nurses while performing simulated work under various lighting conditions. The lighting conditions studied represent design standards consistent with different environments of care—traditional, contemporary, and future. Background: Recent advances in lighting research and technology create opportunities to use lighting in hospital rooms to improve everyday experience and provide researchers with opportunities to explore a new set of research questions about the effects of lighting on patients, guests, and staff. This study focuses on the experience of nurses delivering simulated patient care. Method: Perceptions of each of the 13 lighting conditions were evaluated by nurses using rating scales for difficulty of task completion, comfort, intensity, appropriateness of the lighting color, and naturalness of the lighting during the task. The nurses’ ratings were analyzed alongside qualitative reflections to provide insight into their responses. Results: Significant differences were found for several a priori hypotheses. Interesting findings provide insight into lighting to support circadian synchronization, lighting at night, the distribution of light in the patient room and the use of multiple lighting zones, and the use of colored lighting. Conclusion: The results of this study provide insight into potential benefits and concerns of these new features for patient room lighting systems and reveal gaps in the existing evidence base that can inform future investigations.

Objective:Little is known about the short-term dynamics of methicillin-resistant Staphylococcus aureus (MRSA) transmission between patients and their immediate environment. We conducted a real-life microbiological evaluation of environmental MRSA contamination in hospital rooms in relation to recent patient activity.Design:Observational pilot study.Setting:Two hospitals, hospital 1 in Zurich, Switzerland, and hospital 2 in Ann Arbor, Michigan, United States.Patients:Inpatients with MRSA colonization or infection.Methods:At baseline, the groin, axilla, nares, dominant hands of 10 patients and 6 environmental high-touch surfaces in their rooms were sampled. Cultures were then taken of the patient hand and high-touch surfaces 3 more times at 90-minute intervals. After each swabbing, patients’ hands and surfaces were disinfected. Patient activity was assessed by interviews at hospital 1 and analysis of video footage at hospital 2. A contamination pressure score was created by multiplying the number of colonized body sites with the activity level of the patient.Results:In total, 10 patients colonized and/or infected with MRSA were enrolled; 40 hand samples and 240 environmental samples were collected. At baseline, 30% of hands and 20% of high-touch surfaces yielded MRSA. At follow-up intervals, 8 (27%) of 30 patient hands, and 10 (6%) of 180 of environmental sites were positive. Activity of the patient explained 7 of 10 environmental contaminations. Patients with higher contamination pressure score showed a trend toward higher environmental contamination.Conclusion:Environmental MRSA contamination in patient rooms was highly dynamic and was likely driven by the patient’s MRSA body colonization pattern and the patient activity.

Summary The role of the hospital environment in the transmission of infection is well described. With an emerging infection whose mode of transmission is under investigation, strict infection prevention and control measures, including patient isolation, hand hygiene, personal protective equipment that is doffed on exiting the patient room, and environmental cleaning should be implemented to prevent spread. Environmental testing demonstrated that COVID-19 patients contaminated the patient area (11/26, 42.3% of tests) but contamination of general ward areas was minimal (1/30, 3%) and the virus was detected after cleaning on one item only (1/25, 4%) which was noted to be in disrepair.

Influenza transmission occurs through the air, but the relative importance of small droplets, or aerosols, in influenza transmission especially within healthcare facilities remains uncertain. Detections of influenza virus in aerosols in cough and exhaled breath from infected patients and from the air in outpatient or inpatient healthcare facilities have been studied, but most studies were done in adults with very few data involving children. We aimed to assess the potential of influenza transmission via aerosols in pediatric patient rooms. Two-stage cyclone (NIOSH) air samplers were used to collect the air in 5-bed pediatric patient rooms with patients with influenza-like illness. Influenza A virus RNA was recovered in 15/19 (79%) air sampling occasions with ≥1 patient with laboratory-confirmed influenza A virus infections, in all air size fractions (>4 µm, 1-4 µm and

Trauma anesthesiology is a unique and growing subspecialty. With the growing number of adult and pediatric trauma centers in the United States, a thorough understanding of the early management of severely injured patients with trauma is an important aspect of anesthesia. Trauma anesthesiology requires the ability to adapt to different work environments, including the trauma bay, the operating room, and even the intensive care unit, where a patient room may require conversion to an operating suite for emergencies. This article provides a review of the anesthetic management for patients with extensive trauma, focusing on physiology, pharmacology, and bedside management.

Introduction Change in bowel movement is a common complaint in frail patients, which can be indicative of conditions such as constipation, infection or malnutrition. Without prompt action, this can result in increased length of stay. The recording of stools can be variable. This quality improvement project was to improve stool chart completion rate and staff confidence. Methods We conducted two Plan-Do-Study-Act cycles over three months. We surveyed multidisciplinary staff confidence using Likert scales covering each element on the Bristol stool chart. We then reviewed patient stool charts. The first intervention was a poster. The second intervention was the addition of a sticker to the charts to help staff more easily identify them in the patient’s bedside notes. Staff-wide emails were sent to inform every one of the interventions and key stakeholders including ward managers were asked to hand this over. Results 44 multidisciplinary staff were interviewed and 217 individual stool charts assessed over a 3 month period. 43% of stool charts were not filled in as directed after the first cycle. Posters improved staff confidence in filling out the charts from 72.3% to 92.3% after the second cycle, while 61% of stool charts came to be filled in correctly - over the initial 57%. Healthcare assistants consistently scored the highest in terms of believing charts to be up to date being whereas doctors remained the most cynical. There was little sustained change in stool chart completion rates after three PDSA cycles. Eventually, after both interventions, completion rates returned to baseline. Conclusions Stool chart completion rates can be improved in the short term, but sustainability is a challenge. Factors contributing to this include the variable number of agency nurses. Further improvements include teaching at the nursing induction.