Background Older adults with acute fractures often have suboptimal pain control, in particular those with cognitive impairment. Effective pain management improves rehabilitation engagement and earlier discharge from acute care. Our study aimed to evaluate pain management of older adults with acute fracture admitted under an orthopaedic service in a tertiary hospital. Methods Prospective review of patients over 65 years with an acute fracture admitted under an orthopaedic service. Review of chart, medication prescription and pain status. Data included type of fracture, comorbidities, cognitive status and analgesia prescribed. Data analysed using Excel. Results 40 inpatients included. Median age 82 years (range 65-93 years), 70% female. 53% had cognitive impairment, ranging from mild to severe dementia. 75% had >5 regular medications pre-admission. 80% had >5 comorbidities. Two-thirds (73%) had an acute hip fracture. Most (80%) inpatients had a surgical intervention, the remaining were managed conservatively. Analgesia prescriptions included paracetamol for almost all patients (95%), non-steroidal anti-inflammatory drugs for 3 (8%) and regular opioids in only 3 (8%). 43% of patients reported pain at time of data collection. 13% had analgesia changed in the 24 hours beforehand. Pain adversely affected function in 205 and mobility in 28%. 2 patients were unable to verbalise pain however no pain scales or visual assessments were used. Documentation of pain assessment was best by nurses (100%) followed by doctors (60%) and allied health professionals (40%). Conclusion Older adults with acute fracture are often multimorbid with cognitive impairment. This patient population are often untreated for pain with suboptimal pain assessment and analgesia review or prescriptions. Consequently we developed a pain policy for use on our orthopaedic service as a guide for effective pain assessment and management for older adults with acute fracture.
Background Safeguarding refers to the protection of health and wellbeing and enabling “life free from harm, abuse and neglect” (Safeguarding People 2019 ). In Ireland, the Health Service Executive (HSE) drafted a revised 2019 policy to replace the original policy on safeguarding adults at risk of abuse. A Safeguarding Committee was founded in Beaumont Hospital, Dublin to prepare for policy implementation and staff training. Aims To establish staff awareness and understanding of safeguarding to guide training and policy implementation. Method Cross-sectional study of 223 hospital staff using a 10-question paper survey. Results Suboptimal awareness of the revised HSE policy, reporting structures and confidence levels amongst staff. In-person and online training identified as the most popular methods of learning. Conclusions Knowledge and confidence gaps can be addressed in future training. Identifying education gaps will help guide training and policy implementation. Supplementary information The online version contains supplementary material available at 10.1007/s11845-022-02965-4.
Background Safeguarding is the protection of health, wellbeing and life free from abuse. Abuse is a a violation of a person’s human and civil rights; forms include psychological, financial, physical, sexual, neglect and self-neglect. Health Service Executive (HSE) drafted the 2019 ‘Adult Safeguarding Policy’ for adults at risk of abuse to replace the 2014 version. In preparation for implementation a tertiary hospital founded a Safeguarding Committee in 2021. A core objective was establishing staff understanding, experience of safeguarding and education needs to guide future training. Methods 10-question survey of 223 staff; included doctors, nurses, allied health professionals, medical social workers, healthcare assistants, porters, psychologists. Results 91% response rate. 184 (91%) staff were familiar with the term ‘safeguarding’; only 44% were aware of the HSE 2019 policy. 129 (64%) had experience with a case of suspected abuse. Most common forms were financial, psychological and self-neglect (n = 60, 47, 39 respectively). Sexual abuse was least common (n = 10). 47% felt ‘somewhat’ confident recognising possible abuse compared to 42% who felt ‘extremely’ or ‘very’ confident. 61% were ‘somewhat’ or ‘not so’ confident about the next steps for suspected abuse; only 11% were ‘extremely’ confident. 49% felt ‘extremely’ or ‘very’ confident in reporting a suspected abuse case; 50% felt ‘somewhat’ or ‘not so’ confident. Most common reasons for lack of confidence were lack of training, unclear reporting process and lack of experience with cases of abuse. Medical social workers were most confident; doctors were the least. 170 (84%) wanted more safeguarding training—the most popular options were online or in-person training. Conclusion Gaps in knowledge and confidence were identified amongst staff for cases of suspected abuse. This will guide future training in the hospital in line with the HSE Adult Safeguarding policy.
Background Sedative medications including neuroleptics, benzodiazepines, opioids, ‘z’ drugs and trazadone are commonly prescribed for older adults. Nursing home residents are three times more likely to be prescribed benzodiazepines. Sedative medications are associated with significant risks including falls and delirium in older adults. Neuroleptics also increase risk of cerebrovascular disease and functional decline. Regular medication review and education have been shown to reduce rates of sedative use in nursing homes. Scheduled medication reviews were introduced in an Irish nursing home with a specific focus on reduction or discontinuation of these target medications in combination with education of management of Behavioural and Psychological symptoms (BPSD). We demonstrated previously a significant reduction in prescribing following these interventions. This audit examines the prescribing patterns 3 years on from the initial audit. Methods Point prevalence study of sedative prescriptions and BPSD on 6/5/21 of all 95 nursing home residents. Data compared with two preceding audits in 2018 in the same unit. All data anonymised. Data analysed with SPSS statistical software. Results Significant reduction in quetiapine use sustained from 30% of residents pre-intervention to 14% post-intervention in 2018 and 2021 (p = 0.06). Neuroleptic prescription reduced from 39% to 25% (p = 0.06). ‘Z’ drug prescribing increased from 8% to 17% (p = 0.03). 33% of residents had BPSD reported compared to 49% pre-intervention. Conclusion 3 year follow-up showed regularly scheduled medication reviews and education in a nursing home can effectively rationalise sedative prescription rates. Sustained reduction in neuroleptics and increased ‘z’ drug prescriptions may represent appropriate replacement. Reduced BPSD may be due to changing nursing home resident cohort or reporting bias of staff since the introduction of regular education.
Background Good communication with patients and families is important for older adults admitted to acute stroke or geriatric medicine wards, particularly with COVID19-related restricted visiting. These patients often have communication difficulties including aphasia, delirium, cognitive or hearing impairment, limiting their own communication with relatives. Using the Plan, Do, Study, Act (PDSA) approach we undertook a quality improvement project to optimise communication with families of patients on above wards in a large tertiary hospital. Methods PDSA cycle 1: Staff were surveyed to identify satisfaction level with communication and ways to optimise communication. Inpatients on study wards were identified, we recorded demographic and clinical details and prevalence of communication difficulties. We created a designated folder with individual ‘communication sheets’ in conjunction with ward doctors and the nurse manager. PDSA cycle 2: We performed a rapid interval audit of the communication folder use. ‘Outlier’ patients were excluded as their teams did not receive education about folder use. Results PDSA cycle 1: A total of 90 inpatients on three wards were included, mean age 78y (SD ±14.4y), 47% were male. Three-quarters (73%) had a communication difficulty noted, reported by nursing staff. Two patients were intubated and six had stroke-related aphasia. Half of surveyed staff reported communication with families was suboptimal. Most (86%) suggested a centrally-located communication logbook would be helpful. PDSA cycle 2: Over two weeks, communication sheets were reviewed for all included patients. Median frequency of calls to families was 4 days (range 0–14). Most (79%) had the name of the primary contact clearly documented. Many (52%) included no contact number. Only 9% had secondary contact information documented. Conclusion Communication with families of patients on acute stroke and geriatric medicine wards was suboptimal. Over a short interval this improved with regular phone calls using specific centrally-located communication folders. Further optimisation of their use is needed.
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