P.078 Clinical Milestones in PSP and MSA may be Appropriate Triggers for Palliative Care Intervention

Background: Progressive supranuclear palsy (PSP) and multiple system atrophy (MSA) are progressive neurodegenerative disorders with complex symptom burden and unpredictable disease trajectories. The ideal timing of palliative care interventions is uncertain given the variable natural history of both diseases. Methods: A systematic review was conducted to identify publications investigating predictors of survival in PSP and MSA. A medical librarian assisted to ensure comprehensive search strategy. Relevant literature on palliative care in PSP and MSA was also reviewed. Results from both searches were qualitatively combined in order to suggest triggers for targeted palliative care throughout the disease trajectory. Results: ‘Milestones’ are well documented and clinically relevant disease points that prompt further care. Important milestones include: frequent falls, cognitive impairment, unintelligible speech, severe dysphagia, wheelchair dependence, urinary catheterisation, and nursing home placement. PSP-Richardson syndrome accumulates milestones earlier than PSP-Parkinsonism or MSA. Many PSP patients already have falls and cognitive impairment at the time of diagnosis. Time from milestone to death is variable. Conclusions: Milestones can be used to trace disease progression and help predict survival. Clinical milestones are likely to be important triggers for targeted palliative care interventions including the early incorporation of a palliative approach to care or referral to specialised palliative care services.

Pain induced by investigations and procedures commonly administered to older adults in the emergency department: a prospective cohort study

BackgroundThis study aimed to assess the level of pain induced by common interventions performed in older adults consulting to the ED.MethodsWe conducted a prospective multicentre observational cohort study in two academic EDs (Quebec City, Canada) between June 2018 and December 2019. A convenience sample of well-oriented and haemodynamically stable older adults (≥65 years old) who underwent at least two interventions during their ED stay was recruited. The level of pain was assessed using an 11-point Numerous Rating Scale (NRS) and is presented using median and IQR or categorised as no pain (0), mild (1–3), moderate (4–6) or severe pain (7–10).ResultsA total of 318 patients were included. The mean age was 77.8±8.0 years old and 54.4% were female . The number of pain assessments per intervention ranged between 22 (urinary catheterisation) and 240 (intravenous catheter). All imaging investigations (X-rays, CT and bedside ultrasound) were associated with a median level of pain of 0. The median level of pain for other interventions was as follows: blood samplings (n=231, NRS 1 (IQR 0–3)), intravenous catheters (n=240, NRS 2 (IQR 0–4)), urinary catheterisations (n=22, NRS 4.5 (IQR 2–6)), cervical collars (n=50, NRS 5 (IQR 0–8)) and immobilisation mattresses (n=34, NRS 5 (IQR 0–8)). Urinary catheterisations (63.8%), cervical collars (56.0%) and immobilisation mattresses (52.9%) frequently induced moderate or severe pain.ConclusionsMost interventions administered to older adults in the ED are associated with no or low pain intensity. However, urinary catheterisation and spinal motion restriction devices are frequently associated with moderate or severe pain.

Effectiveness of meatal cleaning in the prevention of catheter-associated urinary tract infections and bacteriuria: an updated systematic review and meta-analysis

ObjectiveA systematic review on meatal cleaning prior to urinary catheterisation and post catheterisation and reduces the risk catheter-associated urinary tract infections (CAUTIs) and bacteriuria was published in 2017, with further studies undertaken since this time. The objective of this paper is to present an updated systematic review on the effectiveness of antiseptic cleaning of the meatal area for the prevention of CAUTIs and bacteriuria in patients who receive a urinary catheter.DesignSystematic review.Data sourcesElectronic databases Cochrane Library, PubMed, Embase, The Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline and Academic Search Complete were searched from 1 January 2016 and 29 February 2020.Eligibility criteriaRandomised controlled trials (RCTs) and quasi-experimental studies evaluating the use of antiseptic, antibacterial or non-medicated agents for cleaning the meatal, periurethral or perineal areas before indwelling catheter insertion or intermittent catheterisation or during routine meatal care.Data extraction and synthesisData were extracted using the Cochrane Collaboration’s data collection form for RCTs and non-RCTs. Data were extracted by one researcher and then checked for accuracy by a second researcher.ResultsA total of 18 studies were included. Some potential benefit of using antiseptics, compared with non-antiseptics for meatal cleaning to prevent bacteriuria and or CAUTI was identified (OR 0.84, 95% CI 0.69 to 1.02; p=0.071). Antiseptics (chlorhexidine or povidine-iodine) may be of value for meatal cleaning on the incidence of CAUTI, compared with comparator agents (saline, soap or antimicrobial cloths) (OR=0.65, 95% CI 0.42 to 0.99; p=0.047).ConclusionThere is emerging evidence of the role of some specific antiseptics (chlorhexidine) prior to urinary catheterisation, in reducing CAUTIs, and some potential benefit to the role of antiseptics more generally in reducing bacteriuria.PROSPERO registration numberCRD42015023741.

Neurological induced incontinence in people with multiple sclerosis

Background: People with multiple sclerosis (MS) are predisposed to neurological induced incontinence due to the pathophysiology of the disease. Aims: This short article aims to discuss the underpinning rationale of neurological induced incontinence in people with MS and explores urinary catheter options. Urinary catheters will be discussed, exploring different types of catheter, catheter sizing, and information on the manufacturers that can support patients and services as well as procurement needs for staff. Findings: Neurogenic bladder occurs when transmissions between the brain and the bladder are delayed or interrupted. While some people are born with neurogenic bladder issues, in the case of MS patients, the disease's effect on the brain through the development of lesions leads to progressively worsening body functions, quite often in the lower extremities. Conclusions: As bladder function degrades due to neurogenic bladder, patients with MS can experience frequent, painful or urgent urination, urinary incontinence, and urinary retention. Urinary catheterisation may be an option they use to manage their symptoms and may enhance their quality of life, enabling them to continue with other activities of daily living.

Effectiveness of a simple intervention for prevention of catheter-associated urinary tract infections on a medical hospital unit

Background: Urinary tract infections (UTI) are one of the most common hospital-acquired infections with 80% as a result of urinary catheterisation. Aim/Objective: This study examined the impact of a simple intervention consisting of a daily chart reminder in patients with indwelling urinary catheters (IUC) on the duration of catheter use and the incidence of catheter-associated UTIs (CAUTIs). Methods: The trial used a prospective pretest–post-test design with a control group over a six-month period conducted on two medical units of a community teaching hospital. We included all patients admitted to two medical units between 1 June and 30 November 2016 who had an IUC inserted at the study site. During the intervention phase, a sticker was placed in the charts of patients with urinary catheters reminding physicians to assess for catheter removal if not clinically necessary. Results: A total of 195 patients participated in this study (112 control unit, 83 intervention unit). There was a decrease in the duration of IUC use on the intervention unit from 11.7 days to 7.5 days ( P = 0.0028). There was a decrease in repeated catheterisation from 11.1% to 2.1% ( P = 0.0882), and CAUTIs from 17.5% to 4.6% ( P = 0.0552) but this did not reach statistical significance. Discussion: The implementation of a daily IUC reminder sticker in patient charts was associated with a significant reduction in the mean duration of indwelling catheter use with a trend towards a reduction in the frequency of repeated urinary catheterisation and rate of CAUTIs.

Comparing national point prevalence surveys of healthcare-associated infection and antimicrobial prescribing: a methodological approach to adjust for differences in case-mix

Background: National point prevalence surveys (PPS) of healthcare-associated infection (HAI) and antimicrobial prescribing in hospitals were conducted in 2011 and 2016 in Scotland. When comparing results of PPS, it is important to adjust for any differences in patient case-mix that may confound the comparison. Aim: To describe the methodology used to compare prevalence for the two surveys and illustrate the importance of taking case-mix (patient and hospital stay characteristics) into account. Methods: Multivariate models (clustered logistic regression) that adjusted for differences in patient case-mix were used to describe the difference in prevalence of six outcomes (HAI, antimicrobial prescribing and four devices: central vascular catheter, peripheral vascular catheter, urinary catheterisation and intubation) between the 2011 and 2016 PPS. Univariate models that did not adjust for these differences were also developed for comparison to show the importance of adjusting for confounders. Results: Without adjustment for case-mix, HAI and intubation prevalence estimates were not significantly different in 2016 compared with 2011 although with adjustment, the prevalence of both was significantly lower ( P=0.03 and P=0.02, respectively). These associations were only identified after adjustment for confounding by case-mix. Conclusions: While prevalence surveys do not provide intelligence on temporal trends as an incidence-based surveillance system would, if limitations and caveats are acknowledged, it is possible to compare two prevalence surveys to describe changing epidemiology. Adjusting for differences in case-mix is essential for robust comparisons. This methodology may be useful for other countries that are conducting large, repeated prevalence surveys.