Implementation of a Frailty Care Bundle (FCB) Targeting Mobilisation, Nutrition and Cognitive Engagement to Reduce Hospital Associated Decline in Older Orthopaedic Trauma Patients: Pretest-Posttest Intervention Study.

Objective: To implement and evaluate a Frailty Care Bundle (FCB) targeting mobilisation, nutrition, and cognition in older trauma patients to reduce hospital associated decline. Methods: We used a two group, pretest-posttest design. The FCB intervention was delivered on two orthopaedic wards and two rehabilitation wards, guided by behaviour change theory (COM-B) to implement changes in ward routines (patient mobility goals, nurse assisted mobilisation, mealtimes, communication). Primary outcomes were patient participants' return to pre-trauma functional capability (modified Barthel Index - mBI) at 6-8 weeks post-hospital discharge and average hospital daily step-count. Statistical analysis compared pre versus post FCB group differences using ordinal regression and log-linear models. Results: We recruited 120 patients (pre n=60 and post n=60), and 74 (pre n=43, post n=36) were retained at follow-up. Median age was 78 years and 83% were female. There was a non-significant trend for higher mBI scores (improved function) in the post compared to pre FCB group (OR 2.29, 95% CI 0.98-5.36), associated with an average 11% increase in step-count. Conclusion: It was feasible, during the Covid-19 pandemic, for multidisciplinary teams to implement elements of the FCB. Clinical facilitation supported teams to prioritise fundamental care above competing demands, but sustainability requires ongoing attention. ISRCTN registry: ISRCTN15145850 (https://doi.org/10.1186/ISRCTN15145850).

Core requirements of frailty screening in the emergency department: an international Delphi consensus study.

INTRODUCTION: Frailty is associated with adverse outcomes among patients attending emergency departments (EDs). While multiple frailty screens are available, little is known about which variables are important to incorporate and how best to facilitate accurate, yet prompt ED screening. To understand the core requirements of frailty screening in ED, we conducted an international, modified, electronic two-round Delphi consensus study. METHODS: A two-round electronic Delphi involving 37 participants from 10 countries was undertaken. Statements were generated from a prior systematic review examining frailty screening instruments in ED (logistic, psychometric and clinimetric properties). Reflexive thematic analysis generated a list of 56 statements for Round 1 (August-September 2021). Four main themes identified were: (i) principles of frailty screening, (ii) practicalities and logistics, (iii) frailty domains and (iv) frailty risk factors. RESULTS: In Round 1, 13/56 statements (23%) were accepted. Following feedback, 22 new statements were created and 35 were re-circulated in Round 2 (October 2021). Of these, 19 (54%) were finally accepted. It was agreed that ideal frailty screens should be short (<5 min), multidimensional and well-calibrated across the spectrum of frailty, reflecting baseline status 2-4 weeks before presentation. Screening should ideally be routine, prompt (<4 h after arrival) and completed at first contact in ED. Functional ability, mobility, cognition, medication use and social factors were identified as the most important variables to include. CONCLUSIONS: Although a clear consensus was reached on important requirements of frailty screening in ED, and variables to include in an ideal screen, more research is required to operationalise screening in clinical practice.

Establishing the core elements of a frailty at the front door model of care using a modified real-time Delphi technique.

BACKGROUND: Innovations in models of care for older adults living with frailty presenting to the emergency department (ED) have become a key priority for clinicians, researchers and policymakers due to the deleterious outcomes older adults experience due to prolonged exposure to such an environment. This study aimed to develop a set of expert consensus-based statements underpinning operational design, outcome measurement and evaluation of a Frailty at the Front Door (FFD) model of care for older adults within an Irish context. METHODS: A modified real-time Delphi method was used. Facilitation of World Café focus groups with an expert panel of 86 members and seperate advisory groups with a Public and Patient Involvement panel of older adults and members of the Irish Association of Emergency Medicine generated a series of statements on the core elements of the FFD model of care. Statements were analysed thematically and incorporated into a real-time Delphi survey, which was emailed to members of the expert panel. Members were asked to rank 70 statements across nine domains using a 9-point Likert scale. Consensus criteria were defined a priori and guided by previous research using 9-point rating scales. RESULTS: Fifty members responded to the survey representing an overall response rate of 58%. Following analyses of the survey responses, the research team reviewed statements for content overlap and refined a final list of statements across the following domains: aims and objectives of the FFD model of care; target population; screening and assessment; interventions; technology; integration of care; evaluation and metrics; and research. CONCLUSION: Development of a consensus derived FFD model of care represents an important step in generating national standards, implementation of a service model as intended and enhances opportunities for scientific impact. Future research should focus on the development of a core outcome set for studies involving older adults in the ED.

A realist process evaluation of an intervention to promote competencies in interprofessional collaboration among interdisciplinary integrated care teams for older people: Study protocol.

Background: International policy is increasingly committed to placing interdisciplinary team-working at the centre of health and social care integration across the lifespan. The National Clinical Programme for Older People in Ireland has a critical role in the design and implementation of the National Older Person's Service Model, which aims to shift the delivery of care away from acute hospitals towards community-based care. Interdisciplinary Community Specialist Teams for older persons (CST-OPs) play an important role in this service model. To support the development of competencies for interprofessional collaboration and an interdisciplinary team-based approach to care integration, a culture shift will be required within care delivery. Design:This study builds upon a collaborative partnership project which co-designed a framework describing core competencies for interprofessional collaboration in CST-OPs. A realist-informed process evaluation of the framework will be undertaken as the competencies described in the framework are being fostered in newly developed CST-OPs under the national scale-up of the service model. Realist evaluation approaches reveal what worked, why it worked (or did not), for whom and under what circumstances. Three iterative and integrated work packages are proposed which combine multiple methods of data collection, analysis and synthesis. Prospective data collection will be undertaken within four CST-OPs, including qualitative exploration of the care experiences of older people and family carers. Discussion: The realist explanatory theory will provide an understanding of how interprofessional collaboration can be fostered and sustained in various contexts of care integration for older people. It will underpin curriculum development for team-based education and training of health and social care professionals, a key priority area in the national Irish health strategy. It will provide healthcare leaders with knowledge of the resources and supports required to harness the benefits of interprofessional collaboration and to realise the goals of integrated care for older people.

Call to action: a five nations consensus on the use of intravenous zoledronate after hip fracture.

Currently in the UK and Ireland, after a hip fracture most patients do not receive bone protection medication to reduce the risk of refracture. Yet randomised controlled trial data specifically examining patients with hip fracture have shown that intravenous zoledronate reduces refracture risk by a third. Despite this evidence, use of intravenous zoledronate is highly variable following a hip fracture; many hospitals are providing this treatment, whilst most are currently not. A range of clinical uncertainties, doubts over the evidence base and practical concerns are cited as reasons. This paper discusses these concerns and provides guidance from expert consensus, aiming to assist orthogeriatricians, pharmacists and health services managers establish local protocols to deliver this highly clinically and cost-effective treatment to patients before they leave hospital, in order to reduce costly re-fractures in this frail population.

Development of a Frailty Index in the Irish Hip Fracture Database.

INTRODUCTION: In older people, hip fracture can lead to adverse outcomes. Frailty, capturing biological age and vulnerability to stressors, can indicate those at higher risk. We derived a frailty index (FI) in the Irish Hip Fracture Database (IHFD) and explored associations with prolonged length of hospital stay (LOS ≥ 30 days), delirium, inpatient mortality and new nursing home admission. We assessed whether the FI predicted those outcomes independently of age, sex and pre-operative American Society of Anaesthesiology (ASA) score. MATERIALS AND METHODS: A 21-item FI was constructed with 17 dichotomous co-morbidities, three 4-level ordinal pre-morbid functional variables (difficulty with indoor mobility, outdoor mobility, and shopping) and nursing home provenance (yes/no). The FI was computed as the proportion of items present and divided into tertiles (low, medium, high risk). Independent associations between FI and outcomes were explored with logistic regression, from which we extracted adjusted Odds Ratios (aOR) and Areas Under the Curve (AUC). RESULTS: From 2017 to 2020, the IHFD included 14,615 hip fracture admissions, mean (SD) age 80.4 (8.8), 68.9% women. Complete FI data were available for 12,502 (85.5%). By FI tertile (low to high risk), prolonged LOS proportions were 5.9%, 16.1% and 23.1%; delirium 5.5%, 13.5% and 17.6%; inpatient mortality 0.6%, 3.3% and 10.1%; and new nursing home admission 2.2%, 5.9% and 11.3%. All associations were statistically significant (p < 0.001) independently of age and sex. AUC analyses showed that the FI score, added to age, sex, and ASA score, significantly improved the prediction of delirium and new nursing home admission (p < 0.05), and especially prolonged LOS and inpatient mortality (p < 0.001). CONCLUSIONS: A 21-item FI in the IHFD was a significant predictor of outcomes and added value to traditional risk markers. The utility of a routinely derived FI to more effectively direct limited orthogeriatric resources requires prospective investigation.

Developing a minimum common dataset for hip fracture audit to help countries set up national audits that can support international comparisons.

AIMS: The aim of this study was to explore current use of the Global Fragility Fracture Network (FFN) Minimum Common Dataset (MCD) within established national hip fracture registries, and to propose a revised MCD to enable international benchmarking for hip fracture care. METHODS: We compared all ten established national hip fracture registries: England, Wales, and Northern Ireland; Scotland; Australia and New Zealand; Republic of Ireland; Germany; the Netherlands; Sweden; Norway; Denmark; and Spain. We tabulated all questions included in each registry, and cross-referenced them against the 32 questions of the MCD dataset. Having identified those questions consistently used in the majority of national audits, and which additional fields were used less commonly, we then used consensus methods to establish a revised MCD. RESULTS: A total of 215 unique questions were used across the ten registries. Only 72 (34%) were used in more than one national audit, and only 32 (15%) by more than half of audits. Only one registry used all 32 questions from the 2014 MCD, and five questions were only collected by a single registry. Only 21 of the 32 questions in the MCD were used in the majority of national audits. Only three fields (anaesthetic grade, operation, and date/time of surgery) were used by all ten established audits. We presented these findings at the Asia-Pacific FFN meeting, and used an online questionnaire to capture feedback from expert clinicians from different countries. A draft revision of the MCD was then presented to all 95 nations represented at the Global FFN conference in September 2021, with online feedback again used to finalize the revised MCD. CONCLUSION: The revised MCD will help aspirant nations establish new registry programmes, facilitate the integration of novel analytic techniques and greater multinational collaboration, and serve as an internationally-accepted standard for monitoring and improving hip fracture services. Cite this article: Bone Joint J 2022;104-B(6):721-728.

Impact of COVID-19 on hip fracture care in Ireland: findings from the Irish Hip Fracture Database.

PURPOSE: To describe the impact of COVID-19 on hip fracture care during the first 6 months of the pandemic. METHODS: A secondary analysis of 4385 cases in the Irish Hip Fracture Database from 1st June 2019 to 31st August 2020 was conducted. RESULTS: Hip fracture admissions decreased by 15% during the study period (p < 0.001). Patient characteristics were largely unchanged as the majority of cases occurred in females over 80 years admitted from home. Adherence to many of the Irish Hip Fracture Standards (IHFS) changed following the COVID-19 pandemic. There was an increase in patients admitted to an orthopaedic ward from Emergency Department (ED) within 4 h from 27 to 36% (p < 0.001). However, the proportion of patients reviewed by a geriatrician reduced from 85% pre-COVID to 80% (p < 0.001). Fewer patients received a bone health assessment [90% from 95% (p < 0.001)] and specialist falls assessment [(82% from 88% (p < 0.001)]. No change was seen in time to surgery or incidence of pressure injuries. There was a significant decrease in length of stay from 18 to 14 days (p < 0.001). There was an increase in patients discharged home during the COVID-19 period and a decrease in patients discharged to rehabilitation, convalescence or nursing home care. There was no statistically significant change in mortality. CONCLUSION: Healthcare services were widely restructured during the pandemic, which had implications for hip fracture patients. There was a notable change in compliance with the IHFS. Multidisciplinary teams involved in hip fracture care should be preserved throughout any subsequent waves of the pandemic.

Early identification of frailty: Developing an international delphi consensus on pre-frailty.

BACKGROUND: Frailty is associated with a prodromal stage called pre-frailty, a potentially reversible and highly prevalent intermediate state before frailty becomes established. Despite being widely-used in the literature and increasingly in clinical practice, it is poorly understood. OBJECTIVE: To establish consensus on the construct and approaches to diagnose and manage pre-frailty. METHODS: We conducted a modified (electronic, two-round) Delphi consensus study. The questionnaire included statements concerning the concept, aspects and causes, types, mechanism, assessment, consequences, prevention and management of pre-frailty. Qualitative and quantitative analysis methods were employed. An agreement level of 70% was applied. RESULTS: Twenty-three experts with different backgrounds from 12 countries participated. In total, 70 statements were circulated in Round 1. Of these, 52.8% were accepted. Following comments, 51 statements were re-circulated in Round 2 and 92.1% were accepted. It was agreed that physical and non-physical factors including psychological and social capacity are involved in the development of pre-frailty, potentially adversely affecting health and health-related quality of life. Experts considered pre-frailty to be an age-associated multi-factorial, multi-dimensional, and non-linear process that does not inevitably lead to frailty. It can be reversed or attenuated by targeted interventions. Brief, feasible, and validated tools and multidimensional assessment are recommended to identify pre-frailty. CONCLUSIONS: Consensus suggests that pre-frailty lies along the frailty continuum. It is a multidimensional risk-state associated with one or more of physical impairment, cognitive decline, nutritional deficiencies and socioeconomic disadvantages, predisposing to the development of frailty. More research is needed to agree an operational definition and optimal management strategies.

Misdiagnosis of myasthenia gravis presenting with tongue and palatal weakness.

We discuss the case of an elderly male who presented with a history of dysphagia, dysphonia, palatal weakness and a sensation of tongue swelling, each symptom of varying time duration. Myasthenia gravis may have a variety of presentations that include ocular fatigability, respiratory muscle weakness and bulbar symptoms. The variety of these myasthenic syndromes can serve as a barrier to diagnosis and can often result in delayed or incorrect diagnosis. In this report, we present an atypical presentation of a relatively rare condition.

Delayed Diagnosis of Atypical Presentation of Myasthenia Gravis.

Myasthenia gravis is an autoimmune disorder affecting the neuromuscular junction, resulting in muscle fatiguability and weakness. The pathological characteristics of the disorder include ocular weakness resulting in diplopia and/or ptosis. More generally, the disease can result in fluctuant weakness of skeletal muscle, predominantly affecting ocular, bulbar and respiratory muscles. Autoimmunity in this instance is mediated by IgG anti-acetylcholine receptor antibodies that results in an impaired structure of postsynaptic neurotransmission. Approximately 15% of patients with myasthenia gravis present with bulbar symptoms, of which isolated bulbar symptoms are seen only on occasion. As with our patient, this presentation is most commonly seen in men with late-onset myasthenia gravis. We present a case of an 83-year-old male who presented with a 1 year history of dysphagia for solids and fatigable dysarthria. Following a diagnosis of myasthenia gravis, he was initiated on corticosteroid treatment. He later descended into myasthenic crisis, requiring invasive ventilation measures due to a failure of both non-invasive ventilation and intravenous immunoglobulin G (IVIG) to achieve therapeutic goals. LEARNING POINTS: Isolated bulbar symptoms in an elderly man warrants consideration of myasthenia gravis to be included in the differential diagnosis.There is possibly an increased risk of myasthenic crisis in late-onset isolated bulbar myasthenia gravis.Empirical treatment for myasthenia gravis must be administered within a hospital setting, paying attention to respiratory tract infection and corticosteroid treatment as triggers for myasthenic crisis.

Improving hip fracture care in ireland: a preliminary report of the irish hip fracture database.

Introduction. Hip fractures are common injuries in the older persons, with significant associated morbidity and mortality. The Irish Hip Fracture Database (IHFD) was implemented to monitor standards of care against international standards. Methods. The IHFD is a clinically led web-based audit. We summarize the data collected on hip fractures from April 2012 to March 2013 from 8 centres. Results. There were 843 patients with the majority being (70%) female. The 80-89-year age group accounted for the majority of fractures (44%). Most (71%) sustained a fall at home. Intertrochanteric fractures (40%) were most common. Only 28% were admitted to an orthopaedic ward within 4 hours. The majority (97%) underwent surgery with 44% having surgery within 36 hours. Medical optimization (35%) and lack of theatre space (26%) accounted for most of the surgical delay. While 29% were discharged home, 33% were discharged to a nursing home or other long-stay facilities. There was a 4% in-hospital mortality rate. Conclusions. Several key areas in both the database and aspects of patient care needing improvement have been highlighted. The implementation of similar databases has led to improved hip fracture care in other countries and we believe this can be replicated in Ireland.