Marie Therese Cooney

Undertaking a Collaborative Rapid Realist Review to Investigate What Works in the Successful Implementation of a Frail Older Person’s Pathway

We addressed the research question “what factors enable the successful development and implementation of a frail older person’s pathway within the acute setting”. A rapid realist review (RRR) was conducted by adopting the RAMESES standards. We began with a sample of 232 articles via database searches supplemented with 94 additional records including inputs from a twitter chat and a hospital site visit. Our final sample consisted of 18 documents. Following review and consensus by an expert panel we identified a conceptual model of context-mechanism-(resources)-outcomes. There was overall agreement frailty should be identified at the front door of the acute hospital. Significant challenges identified related to organisational boundaries both within the acute setting and externally, the need to shift outcomes to patient orientated ones, to support staff to sustain the pathway by providing ongoing education and by providing role clarity. RRRs can support research such as the systematic approach to improving care for frail older adults (SAFE) study by producing accounts of what works based on a wide range of sources and innovative engagement with stakeholders. It is evident from our provisional model that numerous factors need to combine and interact to enable and sustain a successful frail older person’s pathway.

The systematic approach to improving care for Frail Older Patients (SAFE) study: A protocol for co-designing a frail older person’s pathway

Background: Frailty is the age-accelerated decline across multiple organ systems which leads to vulnerability to poor resolution of homeostasis after a stressor event. This loss of reserve means that a minor illness can result in a disproportionate loss of functional ability. Improving acute care for frail older patients is now a national priority and an important aspect of the National Programme for Older People in Ireland. Evidence suggests that an interdisciplinary approach incorporating rapid comprehensive geriatric assessment and early intervention by an interdisciplinary team can reduces susceptibility to hospitalisation related functional decline. The aim of the Systematic Approach to Improving Care for Frail Older Patients (SAFE) is to develop and explore the process of implementing a model of excellence in the delivery of patient-centred integrated care within the context of frail older people’s acute admissions. Methods: The SAFE study will employ a mixed methodology approach, including a rapid realist review of the current literature alongside a review of baseline data for older people attending the emergency department. Semi-structured interviews will be undertaken to document the current pathway. The intervention processes and outcomes will be jointly co-designed by a patient and public involvement (PPI) group together with the interdisciplinary healthcare professionals from hospital, community and rehabilitation settings. Successive rounds of Plan-Do-Study-Act cycles will then be undertaken to test and refine the pathway for full implementation. Discussion: This research project will result in a plan for implementing an integrated, patient-centred pathway for acute care of the frail older people which has been tested in the Irish setting. During the process of development, each element of the new pathway will be tested in turn to ensure that patient centred outcomes are being realised. This will ensure the resulting model of care is ready for implementation in the context of the Irish health service.

188The Ageing of Major Trauma

Background: Traditionally major trauma has been viewed as a disease of young men involved in high-energy transfer mechanisms. The aim of this study is to describe the demographics, clinical details and outcome of major trauma presenting to a tertiary urban university hospital in Ireland over a 31-month period. Methods: An urban tertiary referral teaching hospital was one of the first institutions in Ireland to contribute to the Trauma Audit & Research Network (TARN) database and has been doing so since September 2013. A number of parameters are presented including demographics, mechanism of injury, Injury Severity Score (ISS), mortality and length of stay. Results: 1,088 patients were included in our TARN dataset from September 1st 2013 – March 31st 2016. 50.7% (n = 551) were male. The mean age at presentation was 63.5 years (standard deviation (SD) 22.1). 582 patients (53.5%) were ≥65 years, with a strong female preponderance 65.6% (n = 382) in that cohort. The most common mechanism of injury was “fall less than 2 meters” (n = 665, 61.1%). In the over 65 years population, 81.7% (n = 367) suffered a fall less than 2 meters. 65.5% had an ISS of 1–14 and 34.4% scored >15. The median ISS was 9 (range 1–57). The mean length of stay was 21.0 days (SD 33.8). 51 patients (5.9%) died, of whom 39 were over the age of 65. Conclusions: Our trauma database included more patients over the age of 65 years than under, and the predominant mechanism of injury was one of low energy i.e. fall from less than 2 meters. Our data is in keeping with other recent studies from large trauma databases. It highlights the need to tailor our major trauma services to the specific needs of the older people.

047The Effectiveness of Stroke Rehabilitation in Older Old Patients Compared to a Group of Younger Stroke Patients

Background: The benefits of rehabilitation post stroke are widely accepted. However, the older old (patients over 80) are underrepresented in previous studies. We aimed to examine whether the benefits differ based on age. Method: All patients admitted to a specialist inpatient rehabilitation hospital post stroke between 2010–2016 were included. Patients were assessed for rehabilitation potential prior to transfer and received an individualised interdisciplinary rehabilitation programme. Admission and discharge Barthel scores were recorded. We analysed the change in Barthel index (BI) and length of stay (LOS) by age group. Results: 185 patients were included, 10 of these were excluded due to death, becoming unwell and self-discharge. Patients (47% men, mean age 77.8, 83% ischaemic strokes) were generally previously independent (81% modified Rankin 0–1). 32.6% of patients admitted for rehabilitation showed no evidence of cognitive impairment, 29.1% had mild cognitive impairment, 22.9% moderate cognitive impairment and 11.4% severe cognitive impairment. Mean increase in Barthel did not differ across the age groups and there was no significant difference in LOS. For all age groups, the mean BI on admission was 13 (4.7 SD), 15.6 on discharge (4.34 SD) with a mean LOS of 82 days. In the under 65’s (n = 13), the mean BI on admission was 13.8 (6.1 SD), 16.1 (4.9 SD) on discharge with a mean LOS of 78 days (70 SD). Over 85 s (n = 35), mean BI on admission 11(4.2 SD), 13.3 (4.8 SD) on discharge, LOS 89 days (67 SD).The mean change in BI was 2.9 for the 76–85 group and 2.3 for other age groups. p values for BI change and LOS trends across age groups were non-significant. 81% of patients were discharged home. Conclusion: Stroke rehabilitation can be as effective in older old people as in younger people. Age should not be a barrier to access rehabilitation and selection criteria should be the same as their younger counterparts.