What we need as we get older : needs assessment for the development of a community geriatrics service in an Australian context

Background: The aim of this study was to inform the development of a Community Geriatrics Service (CGS) that addressed the healthcare and social needs of community dwelling older people in an Australian context. Methods: Stakeholders (N = 108) took part in a ‘needs assessment’ involving 30-min semi-structured interviews with general practitioners (GPs; N = 49), and three 2-h focus groups (community engagement meetings; N = 59) with older people, informal caregivers, allied healthcare workers, and nursing home directors. Data were transcribed and thematically coded, mapped to source and weighted to the frequency that the theme was raised across sources. Results: Five themes informing CGS development and delivery emerged: active health conditions (management of behavioural and psychological symptoms of dementia, falls, multimorbidity, and other relevant conditions), active social challenges (patient non-compliance, need for aged care social workers, caregiver stress, elder abuse, social isolation, and stigma), referrals (availability of specialists, communication, specialist input, and advance care directives), access (lack of transport options, and inaccessibility of local geriatrics clinics and specialists), and awareness (lack of awareness, knowledge, and resources). Conclusions: The CGS will need to address access, referral processes and health system navigation, which were perceived by stakeholders as significant challenges. These findings warrant the development of a CGS with an integrated approach to aged care, pertinent for the health and social needs of the elderly

Effectiveness and analysis of factors predictive of discharge to home in a 4-year cohort in a residential transitional care unit

Objective: The aim of this study was to evaluate the effectiveness and identify factors predictive of home discharge in a cohort of patients admitted to the residential Transitional Aged Care Program (r‐TACP) after a stay in an acute hospital. Methods: A retrospective observational cohort study of patients admitted to a single r‐TACP unit between 1 January 2014 and 31 December 2017 was carried out. Baseline patient characteristics and discharge outcomes were analyzed. Results: Three hundred sixty‐nine patients were admitted during the study period. The discharge outcomes were as follows: 68% returned home, 17% went onto residential care, 14% were readmitted to hospital, and 1% died. Factors associated with not returning home were increased age, increased comorbidities, and lower Barthel Index on admission to the r‐TACP. Conclusion: Our r‐TACP is an effective program that successfully returns the majority (67.8%) of older patients home after an acute hospital admission. Older patients with greater comorbidities and poorer baseline functional status in our program were less likely to return home

“We need a one-stop-shop” : co-creating the model of care for a multidisciplinary memory clinic with community members, GPs, aged care workers, service providers, and policy-makers

Background: Timely diagnosis of dementia has a wide range of benefits including reduced hospital emergency department presentations, admissions and inpatient length of stay, and improved quality of life for patients and their carers by facilitating access to treatments that reduce symptoms, and allow time to plan for the future. Memory clinics can provide such services, however there is no 'gold standard' model of care. This study involved the co-creation of a model of care for a new multidisciplinary memory clinic with local community members, General Practitioners (GPs), policy-makers, community aged care workers, and service providers. Methods: Data collection comprised semi-structured interviews (N=98) with 20 GPs, and three 2-h community forums involving 53 seniors and community/local government representatives, and 25 community healthcare workers. Interviews and community forums were audio-recorded, transcribed verbatim, and coded by thematic analysis using Quirkos. Results: GPs’ attitudes towards their role in assessing people with dementia varied. Many GPs reported that they found it useful for patients to have a diagnosis of dementia, but required support from secondary care to make the diagnosis and assist with subsequent management. Community forum participants felt they had a good knowledge of available dementia resources and services, but noted that these were highly fragmented and needed to be easier to navigate for the patient/carer via a 'one-stop-shop' and the provision of a dementia key worker. Expectations for the services and features of a new memory clinic included diagnostic services, rapid referrals, case management, education, legal services, culturally sensitive and appropriate services, allied health, research participation opportunities, and clear communication with GPs. Participants described several barriers to memory clinic utilisation including transportation access, funding, awareness, and costs. Conclusion: This study demonstrates the importance of working with stakeholders to co-design models of care for people with dementia that take into account the local communities’ needs. Findings pave the way for the development of a potential new “gold standard” memory clinic model of care and operationalise new national clinical guidelines

What do junior doctors at a busy metropolitan teaching hospital want to learn about geriatric medicine and how during their internship year?

Aims: To gain an understanding of what interns would have liked to have learned in the field of geriatric medicine, and how they would like to learn during their internship year. Methods: All 32 interns at St Vincent’s Hospital Sydney were invited to participate in the research study. 22 interns consented and undertook a 30-minute semi-structured interview with a single interviewer. Interns were asked to consider three experiences prior to the interview that they had through their internship year which had educational significance for them. These significant events were explored and a further final unstructured discussion on any other educational topics completed the interview. The interviews were recorded, transcribed and coded using an open axial approach by a single researcher. Themes related to geriatric medicine were analysed for the results. Ethical approval was granted by the parent institution & University. Results: A total of seven interns highlighted educational experiences related to geriatric medicine. Interns highlighted that important areas to cover during a geriatric term include: learning about the multi-disciplinary team (50%), an initial orientation to the practice of geriatric medicine (41%), prescribing sedatives, antipsychotic & analgesic medications (32%), and effective palliative care including the holistic aspects of care (27%). The learning methods interns described as potentially beneficial included: structured and unstructured reflective practice (100%) and learning to be proactive in the working environment for their own education (86%). Poor senior support of interns was identified as potentially limiting their learning opportunities (50%); this was particularly the case in rural locations. Conclusions: This study analyses an area not studied in the literature. There are methodological limitations, including the use of a single researcher for interviewing and coding, which limits reliability of the study. With this qualitative study, we were able to identify themes that are worth considering for local geriatric intern education development

What do interns want to learn during emergency medicine rotations in Australia?

Introduction: Only two pre-2005 studies have investigated interns’ learning expectations from emergency medicine rotations. Objectives: To gain insight into interns’ current expectations and learning outcomes from emergency medicine rotations during their internship year. Method: In 2013, a prospective qualitative survey of 22 of the cohort of 32 interns was conducted at St Vincent’s hospital Sydney. Interns consented and undertook a 30-minute semi-structured interview, where three experiences of educational significance they had during their internship year were explored. The interview concluded with an exploration of any missed educational topics. The interviews were recorded, transcribed and coded using a validated open axial approach. Themes related to emergency medicine were analysed for the results. Ethical approval was granted by Cardiff University & St Vincent’s HRECs. Results: Fourteen interns (64%) highlighted emergency medicine educational experiences. Interns identified managing aggressive patients (23%), conflict resolution (55%) and prioritisation/ time management skills (59%) as their key educational expectations. Two potentially beneficial learning methods the interns described included structured and unstructured reflective practices (100%), learning to be proactive in the working environment for their own education (86%). Poor senior support was identified as the potentially limiting factor to their learning opportunities (50%); this was particularly the case in rural locations. Conclusion: This qualitative study highlights novel Australian intern-developed grounded theory themes, which validate research-established methods to practically improve education to interns at local emergency departments. Examples include focusing education on intern-desired topics and using clinical portfolios to stimulate educational proactivity and enhance reflective practice

Can ambulatory blood pressure machines improve postural blood pressure data collection for geriatric patients admitted to a geriatric ward? : a pilot study

Aims: Are Ambulatory Blood Pressure Monitors (ABPMs) equivalent to nursing measurements of blood pressure (BP) &postural blood pressure? Can ABPMs improve data collection rates for postural BP measurement, improving clinical diagnosis? Methods: Over a combined period of 12 months across a two year period from 2013, 97 geriatric patients were recruited to the study from admissions to St Vincent’s Hospital Sydney. Standard nursing observations were supplemented with readings obtained from an OSCAR-II 24-hour ambulatory blood pressure monitor every 30 minutes during the day and hourly when asleep. Postural blood pressure measurements were collected by nursing staff & manually by the research team using the ABPM. Student’s t test was used to assess differences in blood pressure data which was normally distributed. A Bland-Altman plot (validated to compare two methods of collecting similar clinical data) was used to investigate differences in blood pressure data on patients who had complete set of ABPM & nursing systolic & diastolic, lying & postural readings. Results: Of the 97 patients enrolled in the study, only 29 patients had a complete set of nursing readings & 84 had a complete set of ABPM readings. Of these, 22 patients had a complete set of ABPM & nursing data, which were used for the Bland-Altman analysis. There were no statistically significant differences in blood pressure data collected between ABPM and nursing measurements. The Bland-Altman plot demonstrated considerable variability with the differences in postural drops observed for the two methods, with no unusual trends. Conclusions: This study demonstrates that ABPMs can improve the rates of collection of postural blood pressure readings, aiding clinicians with diagnosis. However our analysis demonstrates variability between ABPM postural measurements and ‘standard nursing readings’. This may be explained by small sample size. A larger study with improved methodology could demonstrate whether there is adequate correlation between the two collection methods

Not-for-resuscitation orders in regional NSW

Aims: Assess the rates, usage and compliance with Not-For- Resuscitation orders (NFR) in a NSW hospital O r a l P r e s e n t e r s Australasian Journal on Ageing, Vol 34 Supplement 1, May 2015, 17–50 29 © 2015 ACOTA Methods: Medical records of patients who had died at a NSW regional hospital between January and May 2014 were reviewed. Information was collected on length of admission, whether an NFR order was completed, by whom, at what point during the admission, and whether the order had been followed or amended. Results: 61 patients died during the study period. 53 (87%) patients had an active NFR order at time of death. Reasons for not having an NFR order included younger age, dying in the Emergency Department, dying prior to review from admitting teams, and unexpected death. Average age of death was 74.8: 76.6 with an NFR order and 62.7 without. 25% of NFR orders were incorrectly completed. Errors included: 3 (5%) contradicting requests, 7 (11%) incomplete forms, and 9 (15%) with no instructions for rapid response. 55% of NFR forms were amended during admission, 49% of these within 72 hours of death, and 17% altered within 6 hours of death

The better investigation of falls and frailty in orthostatic hypotension 2 (BIFFOH-2)

Aims: Primary – Do 24-hour ambulatory blood pressure readings provide a more accurate assessment of postural hypotension in patients admitted with falls or frailty? Secondary – Do other medical diseases or pharmaceutical agents correlate with hypertension or postural hypotension? Methods: Over 12 months within a two year period, 97 geriatric patients were recruited from admissions to a metropolitan hospital geriatrics department. Demographic, medical & pharmaceutical data was collected & frailty scores were calculated using validated methods. Nursing observations were supplemented with readings obtained from an OSCAR-II 24-hour ambulatory blood pressure monitor every half-hourly during daytime & hourly at nighttime. Postural blood pressure readings were collected. Results: There was no difference between blood pressure readings obtained by nurses compared with ABPM readings. Mean systolic and diastolic blood pressures were not lower in those patients admitted with falls or syncope when compared to the control group. We noted several statistically significant associations: mean systolic blood pressure was lower in patients reporting morning dizziness; higher mean systolic blood pressures correlated with a known history of cerebrovascular disease and patients taking anti-hypertensives; lower mean systolic blood pressure was observed in those patients currently taking warfarin. Conclusions: Whilst the primary outcome of this study was not significant, our data highlights an intriguing finding: a statistically significant association between hypotension & warfarin or anti-arrhythmic medications. It is unclear if the hypotensive effect of these medications is cause or effect. Our patient demographic is likely to be representative of most metropolitan geriatric units & we recommend further study into this area

Audit of heart failure management amongst geriatric patients

Poster presentation: Aim: Congestive cardiac failure is associated with significant morbidity and mortality. The National Heart Foundation and Cardiac Society of Australia and New Zealand detail best-practice heart failure (HF) management. (Krum et al. MJA, 2011; 194:8)We audited compliance with same within our geriatric department. Method: Initial audit included 31 HF patients admitted Dec 2012-April 2013. We assessed 10 best-practice HF management items (ECHO [≤1 year], blood count, electrolytes, thyroid function tests [TFT], chest X-ray, ECG, diagnosis confirmation, medications review, referral to community HF team, patient education), and employment of a ‘best practice’ HF checklist stamp. Results: Overall, rates of compliance were- ECHO: 58% (14/31), 92% HF medication review, TFT: 42% (10/31), chest X-ray and ECG: 96%, diagnosis confirmation: 40%, community team referral: 73%, documented education: 17%. None received all 10 best-practice interventions

What we need as we get older : perceptions of elders, carers and community healthcare providers in the Macarthur region of Sydney

Aims: To gain a triangulated understanding of the healthcare and social requirements of community dwelling over 65-year-olds in the Macarthur region of Southwest Sydney. Methods. Patients, carers, Primary Healthcare Workers (GPs), allied healthcare workers and nursing home directors of nursing were invited to participate as part of a service development programme. Invitations were coordinated through the community geriatrician, the local Primary Healthcare Network, the three local state Councils and contacts through Campbelltown and Camden Hospitals. Thirty-minute semi-structured interviews were conducted with healthcare workers and three two-h community engagements meetings were facilitated by the community geriatrician (experienced in qualitative approaches). Data were transcribed and thematically coded by a single analyst, mapped to source and weighted to frequency that the theme was raised across sources. Results. Data were collected between February and September 2016 from multiple hospital, community and patient/ carer sources. Significant themes emerged which included: Primary Healthcare workers (management of multimorbidity, ease of referring to a specialist and delays to seeing a referral), allied healthcare workers (lack of staff to see referrals, reduced funding to run services or innovate) and patients/ carers (lack of podiatry services, lack of understanding of what geriatricians do/ offer, lack of understanding of what services exist in local area). Multiple suggestions were made for improvements which were triangulated across the diverse groups. Conclusions. Access, referral processes and health system navigation are perceived to be significant issues in our area warranting the development of an integrated care approach to aged care pertinent for the healthcare and social needs of the elderly. This has implications for development of community geriatric and wider services to the elderly. Limitations include the use of a single researcher and lack of data saturation at completion