Posts Tagged ‘Geriatrics’

Improving hip fracture care shows way for NHS

By Mike Broad - 13th July 2011 12:02 pm

Improvements in hip fracture care are being driven by national clinical audit, strong support networks and extra payments for hospitals, a report finds.

The National Hip Fracture Database 2011 Report shows significant improvements in the quality of care for the 70,000 patients who sustain the injury each year.

At a time when care of the elderly is giving concern, doctors say the approach on hip fractures provides a practical and achievable model that should now be followed more widely.

The report covers more than 53,000 cases admitted between April 2010 and March 2011, and shows consistent improvements in compliance with the six clinical standards measured.

Since the audit began in 2007 more patients are being admitted promptly to orthopaedic wards; delays for operation have been reduced, with the great majority of patients now having surgery within 48 hours.

Fewer patients develop pressure ulcers; and more have specialist pre-operative assessment by a care of elderly physician. Prevention of future fractures is being addressed too: 71% of patients will receive both falls and bone health assessments before leaving hospital.

In 2009, only 12,983 cases met the standards, compared with 53,433 cases in 2011.

There is still room for improvement with significant variation persisting across the country. Two per cent of medically fit patients still wait more than four days for surgery which has serious implications for their recovery and survival. Furthermore, detailed case mix-adjusted statistical analysis of 30-day mortality reveals that a few hospitals have mortality rates that require detailed attention and further analysis.

Dr Colin Currie, consultant geriatrician and chair of the NHFD implementation group, said: “This report shows how a national audit addressing the care of a serious common injury can make a difference on a national scale. The combination of reliable data, achievable standards, continuous feedback, and available know-how has attracted widespread clinical and managerial support, with real gains in both the quality and cost-effectiveness of hip fracture care.

“Clinical teams can look at their own data, spot problems, work together, make changes, and see measurable benefits resulting for the patients they look after.”

The collaborative leadership between the British Geriatrics Society and the British Orthopaedic Association that created the NHFD has driven positive change at the clinical “sharp end”.

Local multidisciplinary teams have been encouraged to deliver continuous improvement in care, particularly through the advent of innovative NHS funding models designed to incentivise ‘best practice’. These models actively support local management in focusing resources to develop high quality services, and the report suggests this model has potential for wider adoption across the NHS.

Mr Peter Kay, president of the British Orthopaedic Association, said: “The importance of this report cannot be over-stated. Not only does it demonstrate how we can improve the care of some of our frailest and most vulnerable patients, but it also highlights the enormous benefit of aligning NHS funding, as a driver of change, with best clinical practice.”

From March 2012 the audit is set to merge with the Royal College of Physicians’ falls audit and cover other forms of fracture suffered by elderly patients in a re-titled “Falls & Fragility Fractures Audit”.

Read the full report.

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Elderly medicine: researchers figure out function of Alzheimer’s protein

Evidentia - 18th November 2010 10:19 am

Researchers in Melbourne believe they have finally figured out the function for the protein that builds up in the brains of people with Alzheimer’s disease.

It has long been known that amyloid precursor protein (APP) forms plaques in Alzheimer’s patients leading to brain cell death and, ultimately, dementia. However, scientists have struggled to understand whether APP has any positive role to play in cell biology.

A team at the University of Melbourne believes APP is an iron oxidase - a protein whose job it is to convert iron from an unsafe form to a safe one for transport or storage. When APP fails to function properly, as it does in Alzheimer’s disease, iron levels inside neurons mount to toxic levels.

“This opens a big window on Alzheimer’s disease and iron metabolism,” said Ashley Bush of the Mental Health Research Institute, University of Melbourne.

“Although people have attributed several important physiological roles to APP,” added Jack Rogers of Harvard Medical School, “this now gives us an idea of what this critical protein does to underpin its role in iron metabolism.”

Read more.

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Improve care for elderly surgery patients

By Mike Broad - 12th November 2010 12:03 pm

Elderly patients undergoing surgery should receive better care, a review concludes.

Pain management, nutrition and delays were all highlighted as problems by experts from the National Confidential Enquiry into Patient Outcome and Death.

Only 37.5% of patients in the sample were assessed as having received good care; 43.6% had room for improvement in either clinical or organisational care; 12.5% in aspects of both clinical and organisational care; and 6.4% received care that was less than satisfactory.

Senior surgical and anaesthetic figures were quick to blame government targets and hospital management.

In a letter to the Daily Telegraph, the presidents of the Royal College of Surgeons, Royal College of Anaesthetists, British Orthopaedic Association, Association of Surgeons and British Geriatric Society, said: “It is a source of deep frustration to our members that hospitals have become organised to deal quickly with elective operations at the cost of properly managing emergency care. It is common for older patients with complex problems to require the input of a range of specialists, but too often the surgical teams struggle to get this support, because the priorities of their hospital lay elsewhere.

“If hospitals were assessed on how they achieve quality outcomes for all their patients, rather than meeting a narrow range of targets, managers would ensure change happens quickly.”

The presidents suggest that under the coming NHS reforms, GP commissioners could “make a difference” by demanding that their patients are treated by hospitals that can prove the effectiveness of multidisciplinary input into emergency care.

The review analysed the care given to 820 people aged over 80 who died within 30 days of having surgery in England, Wales and Northern Ireland.

Delays in surgery for older people was highlighted as a problem and associated with poor outcomes. They should be subject to regular and rigorous audit in all surgical specialities, it says, and this should take place alongside identifiable agreed standards.

Care of the elderly doctors should be available to older patients undergoing surgery, it also recommends.

It says there is an ongoing need for provision of peri-operative level two and three care to support major surgery in the elderly, particularly those with co-morbidity. For less major surgery extended recovery and high observation facilities in existing wards should be considered.

Management of hypothermia, nutrition and intra-operative low blood pressure should also be prioritised.

The review found that consultant involvement in intra-operative care was high and “in most cases the experience of both the surgeon and anaesthetist was judged to be appropriate to the care needs of the patient”.

Dr Ian Wilson, deputy chairman of the BMA’s consultants committee, said: “This is a valuable contribution to the way elderly treatment are dealt with by the NHS. We agree about the importance of consultant input into the care of older people, and believe it adds to the evidence of the importance of a consultant-based service.

“Unfortunately, financial pressures on the NHS mean hospitals are often reluctant to invest in consultant time to deliver high quality care.”

Read the full report.

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Fusing community and acute geriatrics the future

By Dr Simon Conroy, consultant geriatrician, Mr Jay Banerjee, emergency medicine consultant, and GP Prof Louise Robinson - 30th September 2009 3:58 pm

Our ageing population will naturally lead to an increase in age-related illnesses and greater numbers of frail, older people to be cared for in the community. Soon people over 65 years of age will out-number those under 16 and the oldest of the old, the over 85s, are the fastest growing sector of our population.

With the continuing emphasis on care for those with long term illnesses to be as close to their homes as possible, such responsibility will rest initially with primary and community care teams, although help will undoubtedly be required from our specialist secondary care colleagues in geriatrics and old age psychiatry.

However as the nature of primary care has changed dramatically over the last 10-15 years, so too has the acute care of frail older people.

Previously, much of the acute care and rehabilitation of older people was delivered in acute hospital settings. Now, acute care is delivered predominantly in acute medical units (AMUs), often over very short time periods, with on-going rehabilitation provided in a variety of community settings, including intermediate care schemes (home based or residential) and community hospitals.

Some older patients with complex needs, who would previously been managed in hospitals by geriatricians, may not receive the specialist geriatric component of comprehensive geriatric assessment (CGA), even though they may still access other aspects of care (physiotherapy, occupational therapy etc). The consequence of this change in health care delivery is unclear, but in some centres the outcomes for frail older people attending AMUs and being discharged back into the community setting are worrying - up to 55% are readmitted and 26% die in the following 12 months.

While there is renewed interest in community geriatrics, it may be difficult to persuade both hospitals and primary care trusts to invest in such services. Why would an acute hospital want to fund a scheme which ultimately might lead to a reduction in ‘business’? And why would a PCT want to invest in a post when the post holder will be spending half their time in working in the hospital. One solution would be to develop services which are jointly funded by the PCT and the acute hospital trust and which can jointly benefit both parties.

Such is the rationale behind interface geriatrics; geriatricians working at the front door (either the emergency department or the acute medical unit or both), identifying who needs to be admitted and for how long and who would be better served by a community-based multidisciplinary team. These same geriatricians should be part of this team to ensure an integrated approach.

An Australian trial has shown that a CGA approach spanning primary and secondary care can reduce readmissions by about 25%; similar UK studies are underway.

The community role of the geriatrician, working within a multidisciplinary team, can not only be linked into early expedited discharge support from hospital. More importantly, they may be able to decrease the need for access to acute care settings and unnecessary admissions, as has been shown by several of our colleagues in recent years. Of course, avoiding admissions or readmissions is fine, but the real aim is to improve the quality of care for frail older people. Appropriate resource utilisation and allocation is more important than reducing resource use. These arguments are the currency of the day and may be helpful to colleagues trying to develop services in this challenging economic climate.

So maybe a fusion of community and acute geriatric medicine - the interface geriatrician, is one way by which care for older people can be improved, whilst keeping both commissioners and providers happy!

A British Geriatrics Society conference on Interface Geriatrics will be held on the 5 March 2010. Relevant to all health professionals involved in the care of older people in the community, the event is being supported by the RCGP and the College of Emergency Medicine. Read the details here.

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