The evidence for introducing case-finding for delirium and dementia in older medical inpatients in a New Zealand hospital

Objective The aim of this project was to make the case to the managers of a large urban teaching hospital in New Zealand for the introduction of systematic case-finding for pre-existing cognitive impairment/dementia in older hospital inpatients that screen positive for delirium. Method Two hundred consecutive acute admissions aged 75+ in four medical wards were assessed using the 4AT assessment tool for delirium and the Alzheimer Questionnaire (AQ) for pre-existing cognitive impairment/dementia. Length of stay and mortality at 1 year were also collected. Results Over a third of the sample screened positive for delirium and nearly two-thirds of these also screened positive for dementia. The median length of stay was 5 days for delirium without dementia and 7 days for delirium with dementia, compared to 3 days for those who screened negative for both. After adjustment for age, gender and ethnic group, people who screened positive for delirium (with or without dementia) had 50% longer length of stay ( p < 0.05) and at least double the risk of death ( p < 0.05). Conclusion Older hospital inpatients that screen positive for delirium and dementia using 4AT and AQ have longer lengths of stay and higher mortality. Identification may lead to more timely interventions that help to improve health outcomes and reduce hospital costs.

Development of a Screening Tool for Common Mental Disorders Among General Hospital Inpatients in China

Background: Depression and anxiety disorders are common conditions among general hospital inpatients, but are believed to be under-recognized in China.Methods: A short, practical questionnaire termed the happiness index scale (HIS) was developed for screening co-morbid mental disorders in non-psychiatric clinical settings. The HIS was completed by 1,005 non-psychiatric inpatients in a general hospital in China. The reliability and validity of the HIS were then assessed.Results: The HIS comprised eight items which loaded onto four dimensions: (a) sleep quality; (b) suicidal tendency; (c) depression; and (d) anxiety. These dimensions explained 84.2% of the total variance. Confirmatory factor analysis showed reasonably good fit of the four-factor model (χ2/df = 1.27, p &lt; 0.001, goodness-of-fit index = 0.95, comparative fit index = 0.99, root-mean-square error of approximation = 0.008). The correlation coefficients between each item and the corresponding factor were all &gt; 0.5. Cronbach's α of the entire scale was 0.83, indicating good internal consistency. The area under the ROC curve was 0.95 compared with the original 31-item scale. Using the optimal cut-off score of HIS (mild happiness), the sensitivity and specificity were 0.933 and 0.882, respectively.Conclusions: The new HIS scale is a practical screening tool composed of eight items covering the four most common and important dimensions of mental disorder. The HIS exhibited good reliability and specificity. The HIS is potentially suitable for large-scale screening in busy non-psychiatric clinical settings in China. Further verification using larger samples is warranted.

The prevalence, grouping, and distribution of stressors and their association with anxiety among hospitalized patients

Anxiety is prevalent among hospital inpatients and it has harmful effects on patient well-being and clinical outcomes. We aimed to characterize the sources of hospital distress and their relationship to anxiety. We conducted a cross-sectional study of inpatients (n = 271) throughout two Southeastern U.S. metropolitan hospitals. Participants completed a survey to identify which of 38 stressors they were experiencing. They also completed the State Trait Anxiety Inventory six-item scale. We evaluated the prevalence of stressors, their distribution, and crude association with anxiety. We then used multivariate logistic regression to estimate the association between stressors and clinically relevant anxiety, with and without adjusting for demographic variables. We used factor analysis to describe the interrelationships among stressors and to examine whether groups of stressors tend to be endorsed together. The following stressors were highly endorsed across all unit types: pain, being unable to sleep, feelings of frustration, being overwhelmed, and fear of the unknown. Stressors relating to isolation/meaninglessness and fear/frustration tend to be endorsed together. Stressors were more frequently endorsed by younger, female, and uninsured or Medicaid-insured patients and being female and uninsured was associated with anxiety in bivariate analysis. After controlling for the sources of distress in multivariate linear analysis, gender and insurance status no longer predicted anxiety. Feelings of isolation, lack of meaning, frustration, fear, or a loss of control were predictive. Study results suggest that multiple stressors are prevalent among hospital inpatients and relatively consistent across hospital unit and disease type. Interventions for anxiety or emotional/spiritual burden may be best targeted to stressors that are frequently endorsed or associated with anxiety, especially among young and female patients.

Preexisting Comorbidities Predicting COVID-19 and Mortality in the UK Biobank Community Cohort

Hospitalized COVID-19 patients tend to be older and frequently have hypertension, diabetes or CHD, but whether these co-morbidities are more common than in the general older population is unclear. We estimated associations between pre-existing diagnoses and hospitalized COVID-19 alone or with mortality (during the first COVID-19 outbreak, tests performed between March 16 and April 26, 2020). In 269,070 UK Biobank participants aged 65+, 507 (0.2%) became COVID-19 hospital inpatients, of which 141 (27.8%) died. Common preexisting co-morbidities in hospitalized inpatients were hypertension (59.6%), history of falls/fragility fractures (29.4%), CHD (21.5%), T2 diabetes (19. 9%) and asthma (17.6%). However, in adjusted models, pre-existing diagnoses of dementia, T2 diabetes, COPD, pneumonia, depression, atrial fibrillation and hypertension emerged as independent risk factors for COVID-19 hospitalization, the first five remaining statistically significant for related mortality. There are specific high risk pre-existing co-morbidities for COVID-19 hospitalization and deaths in community based older men and women.

Increasing oxygen prescribing during the COVID-19 pandemic

Valid oxygen prescriptions for hospital inpatients have been a long-standing problem and have been described extensively in BMJ Open Quality with numerous quality improvement projects (QIPs) with the aim of improving compliance with oxygen prescribing.The British Thoracic Society recommends that all inpatients should have oxygen target saturation set on admission: this is motivated by risks of both undertreatment and overtreatment with oxygen. The discrepancy between the recommendation and the reality produced a number of interventions studied in QIPs over the past years, all aiming at bringing the local ward teams closer to the target. This has become even more important during the COVID-19 pandemic, where non-standard oxygen saturation targets and oxygen scarcity led hospital systems to rethink their internal guidelines on the subject.We propose three novel interventions to improve compliance: a remote, personally directed email communication to a ward pharmacist, a similar communication to ward nurses, and a remote, personally directed WhatsApp communication to junior ward doctors. We undertake a QIP which compares novel interventions developed in-house with the most successful interventions from oxygen prescribing initiatives that have previously been published by BMJ Open Quality. The main outcome measure was the proportion of patients with valid oxygen prescription on a ward.The series of novel interventions in three plan, do study, act cycles led to improvement in the outcome measure from 0% at baseline to 70% at the end of the QIP. The successful interventions from previous QIPs were ran in parallel on a similar ward and achieved improvement from 17.9% at baseline to 55.6% at the end of the QIP.This QIP demonstrates adapted interventions performed in context of social distancing aimed at members of multidisciplinary team which achieve superiority in increasing proportion of patients with a valid oxygen prescription, when compared with previously described methods from BMJ Open Quality.

EP.TU.785Quality Improvement Project: Improving Oxygen therapy prescription in surgical inpatients

Aims The 2015, British Thoracic Society (BTS) Oxygen audit demonstrated that 42% of hospital inpatients were using Oxygen without a prescription. National and local standards state that Oxygen, as a drug, should be routinely prescribed and checked along with regular medications and VTE risk assessment. Our baseline audit conducted over a two month period on the surgical wards of a large city hospital revealed that 78% of patients were not being prescribed oxygen. We set a SMART aim to increase the percentage of surgical inpatients being prescribed oxygen by 20% each month. Methods We used the trust e-prescription software to record our data, with three-stage verification and subsequent senior analysis of data. The three primary drivers identified were factors intrinsic to the department: lack of standard awareness, education and safety-net to ensure sustainability. To tackle these in-turns, we designed three PDSA cycles: Departmental poster, seminar with induction material, and system checklist notification. Results Following our first PDSA cycle, the mean percentage increased from 22% to 60%. Using projection analysis, we anticipate this to increase to &gt; 75% after the second PDSA cycle, and &gt;95% after PDSA3, with 100% sustainability one year later. Conclusion Our results to-date show that practice standards have improved following our first PDSA cycle, indicating that awareness played an important role. We predict that education will play an equal role; and given the research supporting the implications of checklists, we forecast that this later element will be the ultimatum leading to 100% sustainability of patients receiving oxygen prescription.

EP.FRI.1036 Provision of 7 Day Radiology Service: Are we compliant against standards

Aim The audit aimed to retrospectively look into reporting times for investigations for acute surgical inpatients and determine if we were able to meet standards as set in NHS 7 day service provision standards which aims to provide 7day radiological service for hospital inpatients from commission to reporting. Method A prospective audit is undertaken to collect waiting times for investigations for all acute admissions requiring radiological investigations over one month. Investigations were categorized into ‘critical’, ‘urgent’ and ‘non-urgent’ according to guidelines set by Royal College of Surgeons. The results were tabulated in Excel and analyzed to determine level of compliance. Results Collected data shows that off the total 119 investigations performed, 34% were USG, 63% were CT scans and 2.5% were MRI. Standards were met for a total of 67% of the investigations. Only 20% of critical, 67% of urgent and 76% of non-urgent scans were done within the standard time while by modality, CT scans had the highest rate of compliance. 60% of investigations requested over weekends met standards with highest compliance for USG and for non-urgent scans. Average reporting time was approximately 50 minutes. Conclusion The audit outcome highlighted that 1 out of 3 investigations did not meet standards. Within its limitations of no numerical parameters to guide urgency, the audit was able give an idea of the radiology service offered by the hospital and highlighted clear areas for improvements which can be suggested to improve compliance such as documenting ‘operative catergory’ of requested investigations on request forms.

Incidentally identified coronary artery calcium on non-contrast CT scan of the chest predicts major adverse cardiac events among hospital inpatients

BackgroundCoronary artery calcium (CAC) identified on non-gated CT scan of the chest is predictive of major adverse cardiac events (MACE) in multiple studies with guidelines therefore recommending the routine reporting of incidental CAC. These studies have been limited however to the outpatient setting. We aimed to determine the prognostic utility of incidentally identified CAC on CT scan of the chest among hospital inpatients.Methods and resultsConsecutive patients (n=740) referred for inpatient non-contrast CT scan of the chest at a tertiary referral hospital (January 2011 to March 2017) were included (n=280) if they had no known history of coronary artery disease, active malignancy or died within 30 days of admission. Scans were assessed for the presence of CAC by visual assessment and quantified by Agatston scoring. Median age was 69 years (IQR: 54–82) and 51% were male with a median CAC score of 7 (IQR 0–205). MACE occurred in 140 (50%) patients at 3.5 years median follow-up including 98 deaths. Half of all events occurred within 18 months. Visible CAC was associated with increased MACE (HR) 6.0 (95% CI: 3.7 to 9.7) compared with patients with no visible CAC. This finding persisted after adjusting for cardiovascular risk factors HR 2.4 (95% CI: 1.3 to 4.3) and with both absolute CAC score and CAC score ≥50th percentile.ConclusionIncidental CAC identified on CT scan of the chest among hospital inpatients provides prognostic information that is independent of cardiovascular risk factors. These patients may benefit from aggressive risk factor modification given the high event rate in the short term.