The Impact of COVID-19 on Hip Fracture Management in a Tertiary Referral Hospital; Pearls and Pitfalls.

Background COVID-19 has caused significant challenges in the provision of safe and effective healthcare globally. Safeguarding the management of frail older adults is imperative in hip fracture care moving forward. Aims This study aimed to compare clinical outcomes of hip fracture care during the COVID-19 pandemic with the same timeframe in 2019, following significant reconfigurations in hip fracture management pathways during the pandemic. Methods We conducted a retrospective study comparing all patients treated for a hip fracture between two timeframes; March 1st2020 - May 1st 2020 and March 1st 2019 – May 1st 2019. Data was collected using the Irish Hip Fracture Database and the UHL electronic patient administration system. Results 118 patients were included in the study; 60 patients in the COVID-19 cohort and 58 patients in the control cohort. Demographic characteristics were comparable between groups. Improvements in adherence to Irish Hip Fracture Standards were noted during the COVID-19 cohort, however they were not significant. Three patients tested positive for COVID-19 during the timeframe of interest. Their length of stay (LOS) was noticeably longer than the median LOS of both groups. A significant decrease in femoral nerve blocks was noted during the COVID-19 cohort (p = < 0.001). There was a trend towards higher inpatient mortality, 30 day mortality rates and 30 day readmission in the COVID-19 cohort which was not statistically significant. ConclusionsOur study demonstrates continued adherence to the Irish Hip Fracture Standards at our institution and suggests the necessary alterations in hip fracture management did not negatively impact patient outcomes during the COVID-19 pandemic.

Predicting outcomes in emergency medical admissions – role of laboratory data and co-morbidity

Background: The utility of risk stratification following an emergency medical admission has been debated. We have examined the predictability of outcomes, from a database of all emergency admissions to St James’ Hospital, Dublin, over a six year period (2005-2010). Methods: Analysis was performed using the hospital in-patient enquiry system, linked to the patient administration system and laboratory data. The utility of a fractional polynomial laboratory only model to predict 30-day in-hospital mortality was determined. Results: The AUROC for the laboratory parameters to predict a 30 day death was 0.90 (95% CI 0.89, 0.90) in the 2002 – 2010 derivation dataset and was 0.88 (95% CI 0.86, 0.90) in the 2011 validation set. The addition of co-morbidity measures did not improve the model prediction (0.89 : 95% CI 0.88 – 0.89). Conclusion: A fractional polynomial laboratory only model can reliably predict 30-day hospital mortality following an emergency medical admission, potentially allowing resources to be risk focused and patients to be prioritised.

Unplanned General Surgical Re-Admissions – How Many, Which Patients and Why?

INTRODUCTION The unplanned re-admission rate is a national key performance indicator employed by the UK Department of Health. An adjusted figure, based on admission information data on the hospital electronic Patient Administration System (PAS), but adjusted to take account of case mix is compared with a calculated ‘expected’. While previous studies have investigated unplanned re-admission rates in age-, procedure- or process-specific conditions, ‘all-cause’ general surgical re-admission rate is yet to be studied. The aim of this study was to assess the accuracy of hospital unplanned re-admission data, and identify patterns or possible causes of unplanned general surgical re-admissions. PATIENTS AND METHODS Retrospective audit of case note records of all patients identified from the hospital electronic PAS as unplanned, general surgical re-admissions over a period of 4 consecutive months. RESULTS Of all 161 re-admissions in this study, 46 (29%) were unrelated to the index admission, planned or involved patient self-discharge during the index admission. Of the ‘genuine’, unplanned re-admissions, 80 (78%) followed an emergency index admission, 58 (56%) had chronic or recurrent symptoms, for which 26 (25%) were on waiting lists. Fourteen (14%) were multiple admissions of 4 patients, while 8 (8%) re-admissions required further surgery for significant postoperative complications. CONCLUSIONS Unplanned. general surgical re-admission rates collated from hospital PAS systems may be inaccurate. Nearly half of ‘genuine’, unplanned re-admissions involved patients with chronic and/or recurrent symptoms, which are predictable and may be preventable. Significant postoperative complications accounted for few re-admissions in this study.

Admission patterns of patients with personality disorder

Aims and MethodTo examine the prevalence and admission patterns of patients with personality disorder admitted to a Scottish general adult psychiatry service. We carried out a retrospective case-note study of patients identified from the computerised patient administration system. A subgroup of patients was identified as having a longer in-patient stay. Their admission pattern over the preceding 4 years was studied further.ResultsSixty-two of 844 patients admitted had personality disorder. Thirty-nine had a primary diagnosis of personality disorder, 19 had an additional diagnosis of psychiatric disorder and 12 of alcohol or substance misuse. Within the subgroup admitted for longer in 2001, patterns of few/brief and numerous/often lengthy admissions were noted in earlier years.Clinical ImplicationsPersonality disorder occurs in approximately 7% of admissions to general adult psychiatry beds. Many have additional diagnoses of psychiatric disorder, or substance or alcohol misuse further complicating their treatment.

Non-attendance rates among patients attending different grades of psychiatrist and a clinical psychologist within a community mental health clinic

Aims and MethodTo examine non-attendance rates in patients seen by psychiatrists of different grades and a consultant clinical psychologist. Rates were obtained from the patient administration system over a 21-month period.ResultsA planned linear contrast showed that the clinical psychologist's patients had the lowest rate of non-attendance (7.8%), followed in turn by those of consultant psychiatrists (18.6%), specialist registrars (34%) and senior house officers (37.5%).Clinical ImplicationsFactors such as continuity of care, perceived clinical competence and the provision of non-medical interventions might have an impact on attendance rates. These results indicate the difficulty in reconciling the training needs of junior doctors with the provision of continuity and quality of care for patients. Reminder systems for people seeing training doctors might be an effective way of reducing non-attendance rates.

Naturalistic study of the antipsychotic medication review service at the Maudsley Hospital

Aims and MethodTo evaluate the effectiveness of the antipsychotic medication review service (AMRS) at the Maudsley Hospital. Patient notes were analysed from the AMRS and estimates of Global Assessment Scale (GAS) scores were made from entries in the notes. Data on hospital admissions before and during attendance at the AMRS were obtained from the trust-wide computerised patient administration system.ResultsA statistically significant improvement in GAS scores was seen for patients who stayed in contact with the AMRS. Patients who did not respond to the first atypical drug often made a good response to an alternative atypical antipsychotic. Patients attending the AMRS had fewer hospital admissions than they did before attendance, although this was not statistically significant.Clinical ImplicationsAlthough more expensive on a dose-by-dose rate, atypical antipsychotics may be cost effective by improving compliance and reducing the number of relapses and hospital admissions. Specialised services with frequent patient contact can be effective in preventing relapse and improving global function.