Publications by authors named "Philip Braude"

19 Publications

  • Page 1 of 1

Emergency management of older people with cervical spine injuries: an expert practice review.

Emerg Med J 2021 Aug 3. Epub 2021 Aug 3.

Emergency Department, Southmead Hospital, Bristol, UK.

Spinal fractures are the third most common traumatic injury in older people, of which cervical spine injuries make up around 15%. They are predominantly seen in people living with frailty who fall from standing height. Spinal fractures in this patient group are associated with substantial morbidity and mortality (over 40% at 1 year). For many older people who survive, their injuries will be life changing. Practice between EDs varies significantly, with no universally accepted guidelines on either assessment, investigation or management specific to older people experiencing trauma. This expert practice review examines the current evidence and emergency management options in this patient group through clinical scenarios, with the aim of providing a more unified approach to management.
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http://dx.doi.org/10.1136/emermed-2020-211002DOI Listing
August 2021

Sadness, despair and anger when a patient dies alone from COVID-19: A thematic content analysis of Twitter data from bereaved family members and friends.

Palliat Med 2021 07 21;35(7):1267-1276. Epub 2021 May 21.

Department for Medicine for Older People, North Bristol NHS Trust, Bristol, UK.

Background: To inform clinical practice and policy, it is essential to understand the lived experience of health and social care policies, including restricted visitation policies towards the end of life.

Aim: To explore the views and experiences of Twitter social media users who reported that a relative, friend or acquaintance died of COVID-19 without a family member/friend present.

Design: Qualitative content analysis of English-language tweets.

Data Sources: Twitter data collected 7-20th April 2020. A bespoke software system harvested selected publicly-available tweets from the Twitter application programming interface. After filtering we hand-screened tweets to include only those referring to a relative, friend or acquaintance who died alone of COVID-19. Data were analysed using thematic content analysis.

Results: 9328 tweets were hand-screened; 196 were included. Twitter users expressed sadness, despair, hopelessness and anger about their experience and loss. Saying goodbye via video-conferencing technology was viewed ambivalently. Clinicians' presence during a death was little consolation. Anger, frustration and blame were directed at governments' inaction/policies or the public. The sadness of not being able to say goodbye as wished was compounded by lack of social support and disrupted after-death rituals. Users expressed a sense of political neglect/mistreatment alongside calls for action. They also used the platform to reinforce public health messages, express condolences and pay tribute.

Conclusion: Twitter was used for collective mourning and support and to promote public health messaging. End-of-life care providers should facilitate and optimise contact with loved ones, even when strict visitation policies are necessary, and provide proactive bereavement support.
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http://dx.doi.org/10.1177/02692163211017026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8267082PMC
July 2021

Multiple House Occupancy is Associated with Mortality in Hospitalised Patients with Covid-19.

Eur J Public Health 2021 May 17. Epub 2021 May 17.

Institute of Applied Health Science, University of Aberdeen, Aberdeen Scotland.

Background: In response to the COVID-19 pandemic, many countries mandated staying at home to reduce transmission. This study examined the association between living arrangements (house occupancy numbers) and outcomes in COVID-19.

Methods: Study population was drawn from the COPE Study, a multicentre cohort study. House occupancy was defined as: living alone; living with one other person; living with multiple other people; or living in a nursing/residential home. Outcomes were time from admission to mortality and discharge (Cox regression), and Day-28 mortality (logistic regression), analyses were adjusted for key comorbidities and covariates including admission: age; sex, smoking; heart failure; admission CRP; COPD; eGFR, frailty and others.

Results: 1584 patients were included from 13 hospitals across UK and Italy: 676 (42.7%) were female, 907 (57.3%) were male, median age was 74 years (range: 19-101). At 28 days, 502 (31.7%) had died. Median admission CRP was 67, 82, 79.5 and 83mg/L for those living alone, with someone else, in a house of multiple occupancy and in a nursing/residential home, respectively. Compared to living alone, living with anyone was associated with increased mortality: within a couple (aHR 1.39, 95%CI 1.09-1.77, p = 0.007); living in a house of multiple occupancy (aHR=1.67, 95%CI 1.17-2.38, p = 0.005); and living in a residential home (aHR=1.36, 95%CI 1.03-1.80, p = 0.031).

Conclusion: For patients hospitalised with COVID-19, those living with one or more people had an increased association with mortality, they also exhibited higher CRP indicating increased disease severity suggesting they delayed seeking care.
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http://dx.doi.org/10.1093/eurpub/ckab085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8247274PMC
May 2021

Developing a virtual geriatric perioperative medicine clinic: a mixed methods healthcare improvement study.

Age Ageing 2021 06;50(4):1391-1396

Geriatric Perioperative Care, North Bristol NHS Trust, Bristol, UK.

Background: the Geriatric Perioperative Care clinic at North Bristol NHS Trust was suspended in March 2020 during the COVID-19 pandemic. A virtual clinic was piloted to deliver preoperative health optimisation and shared decision-making for patients undergoing critical elective surgery. No literature existed on virtual preoperative clinics for older people to support the development.

Objective: this healthcare improvement study describes the setup and delivery of the virtual clinic as its primary aim. Secondary aims included: assessing older people's access to technology and their digital literacy for virtual consultation; to describe barriers and facilitators for consultations, as well as evaluation of patient and clinician satisfaction with the consultations' mode of delivery and outcomes.

Methods: a mixed methods healthcare improvement study was undertaken through plan-do-study-act cycles, semi-structure interviews, and quantitative service benchmarking.

Results: the pilot evaluated 67 preoperative consultations (43.3% video, 56.7% telephone, mean age 75) with a mix of surgical pathology (vascular 88.1%, colorectal 10.4%, urological 1.5%). Patient feedback demonstrated improved understanding of conditions (90.6%), and adequate opportunity to express opinions and questions (96.2%). Clinicians preferred video consultations (adequate to deliver services: 89.7% video; 68.4% telephone). The greatest barriers to engagement, none of which were exclusions to participation, included cognitive impairment, sensory impairment, or needing technical assistance setting up video consultations (52.2%).

Conclusions: delivering a virtual preoperative medical optimisation and shared decision clinic for older people is feasible. This study will aid other units in developing their own virtual preoperative clinics. Future work should evaluate perioperative outcomes of delivering a face-to-face versus virtual clinic.
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http://dx.doi.org/10.1093/ageing/afab066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8240915PMC
June 2021

The role of C-reactive protein as a prognostic marker in COVID-19.

Int J Epidemiol 2021 05;50(2):420-429

Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.

Background: C-reactive protein (CRP) is a non-specific acute phase reactant elevated in infection or inflammation. Higher levels indicate more severe infection and have been used as an indicator of COVID-19 disease severity. However, the evidence for CRP as a prognostic marker is yet to be determined. The aim of this study is to examine the CRP response in patients hospitalized with COVID-19 and to determine the utility of CRP on admission for predicting inpatient mortality.

Methods: Data were collected between 27 February and 10 June 2020, incorporating two cohorts: the COPE (COVID-19 in Older People) study of 1564 adult patients with a diagnosis of COVID-19 admitted to 11 hospital sites (test cohort) and a later validation cohort of 271 patients. Admission CRP was investigated, and finite mixture models were fit to assess the likely underlying distribution. Further, different prognostic thresholds of CRP were analysed in a time-to-mortality Cox regression to determine a cut-off. Bootstrapping was used to compare model performance [Harrell's C statistic and Akaike information criterion (AIC)].

Results: The test and validation cohort distribution of CRP was not affected by age, and mixture models indicated a bimodal distribution. A threshold cut-off of CRP ≥40 mg/L performed well to predict mortality (and performed similarly to treating CRP as a linear variable).

Conclusions: The distributional characteristics of CRP indicated an optimal cut-off of ≥40 mg/L was associated with mortality. This threshold may assist clinicians in using CRP as an early trigger for enhanced observation, treatment decisions and advanced care planning.
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http://dx.doi.org/10.1093/ije/dyab012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7989395PMC
May 2021

Routine use of immunosuppressants is associated with mortality in hospitalised patients with COVID-19.

Ther Adv Drug Saf 2021 18;12:2042098620985690. Epub 2021 Feb 18.

Department of Geriatric Medicine, 3rd Floor Academic Centre, Llandough Hospital, Penlan Road, Penarth, CF64 2XX.

Background: Whilst there is literature on the impact of SARS viruses in the severely immunosuppressed, less is known about the link between routine immunosuppressant use and outcome in COVID-19. Consequently, guidelines on their use vary depending on specific patient populations.

Methods: The study population was drawn from the COPE Study (COVID-19 in Older People), a multicentre observational cohort study, across the UK and Italy. Data were collected between 27 February and 28 April 2020 by trained data-collectors and included all unselected consecutive admissions with COVID-19. Load (name/number of medications) and dosage of immunosuppressant were collected along with other covariate data. Primary outcome was time-to-mortality from the date of admission (or) date of diagnosis, if diagnosis was five or more days after admission. Secondary outcomes were Day-14 mortality and time-to-discharge. Data were analysed with mixed-effects, Cox proportional hazards and logistic regression models using non-users of immunosuppressants as the reference group.

Results: In total 1184 patients were eligible for inclusion. The median (IQR) age was 74 (62-83), 676 (57%) were male, and 299 (25.3%) died in hospital (total person follow-up 15,540 days). Most patients exhibited at least one comorbidity, and 113 (~10%) were on immunosuppressants. Any immunosuppressant use was associated with increased mortality: aHR 1.87, 95% CI: 1.30, 2.69 (time to mortality) and aOR 1.71, 95% CI: 1.01-2.88 (14-day mortality). There also appeared to be a dose-response relationship.

Conclusion: Despite possible indication bias, until further evidence emerges we recommend adhering to public health measures, a low threshold to seek medical advice and close monitoring of symptoms in those who take immunosuppressants routinely regardless of their indication. However, it should be noted that the inability to control for the underlying condition requiring immunosuppressants is a major limitation, and hence caution should be exercised in interpretation of the results.

Plain Language Summary: We do not have much information on how the COVID-19 virus affects patients who use immunosuppressants, drugs which inhibit or reduce the activity of the immune system. There are various conflicting views on whether immune-suppressing drugs are beneficial or detrimental in patients with the disease. This study collected data from 10 hospitals in the UK and one in Italy between February and April 2020 in order to identify any association between the regular use of immunosuppressant medicines and survival in patients who were admitted to hospital with COVID-19. 1184 patients were included in the study, and 10% of them were using immunosuppressants. Any immunosuppressant use was associated with increased risk of death, and the risk appeared to increase if the dose of the medicine was higher. We therefore recommend that patients who take immunosuppressant medicines routinely should carefully adhere to social distancing measures, and seek medical attention early during the COVID-19 pandemic.
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http://dx.doi.org/10.1177/2042098620985690DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897811PMC
February 2021

The influence of ACE inhibitors and ARBs on hospital length of stay and survival in people with COVID-19.

Int J Cardiol Heart Vasc 2020 Dec 15;31:100660. Epub 2020 Oct 15.

Cardiff University and Honorary Consultant Physician, Aneurin Bevan University Health Board, UK.

Objective: During the COVID-19 pandemic the continuation or cessation of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) has been contentious. Mechanisms have been proposed for both beneficial and detrimental effects. Recent studies have focused on mortality with no literature having examined length of hospital stay. The aim of this study was to determine the influence of ACEi and ARBs on COVID-19 mortality and length of hospital stay.

Methods: COPE (COVID-19 in Older People) is a multicenter observational study including adults of all ages admitted with either laboratory or clinically confirmed COVID-19. Routinely generated hospital data were collected. Primary outcome: mortality; secondary outcomes: Day-7 mortality and length of hospital stay. A mixed-effects multivariable Cox's proportional baseline hazards model and logistic equivalent were used.

Results: 1371 patients were included from eleven centres between 27th February to 25th April 2020. Median age was 74 years [IQR 61-83]. 28.6% of patients were taking an ACEi or ARB. There was no effect of ACEi or ARB on inpatient mortality (aHR = 0.85, 95%CI 0.65-1.11). For those prescribed an ACEi or ARB, hospital stay was significantly reduced (aHR = 1.25, 95%CI 1.02-1.54, p = 0.03) and in those with hypertension the effect was stronger (aHR = 1.39, 95%CI 1.09-1.77, p = 0.007).

Conclusions: Patients and clinicians can be reassured that prescription of an ACEi or ARB at the time of COVID-19 diagnosis is not harmful. The benefit of prescription of an ACEi or ARB in reducing hospital stay is a new finding.
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http://dx.doi.org/10.1016/j.ijcha.2020.100660DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7561344PMC
December 2020

Study protocol for the COPE study: COVID-19 in Older PEople: the influence of frailty and multimorbidity on survival. A multicentre, European observational study.

BMJ Open 2020 09 29;10(9):e040569. Epub 2020 Sep 29.

Geriatric Medicine, Cardiff University, Cardiff, UK.

Introduction: This protocol describes an observational study which set out to assess whether frailty and/or multimorbidity correlates with short-term and medium-term outcomes in patients diagnosed with COVID-19 in a European, multicentre setting.

Methods And Analysis: Over a 3-month period we aim to recruit a minimum of 500 patients across 10 hospital sites, collecting baseline data including: patient demographics; presence of comorbidities; relevant blood tests on admission; prescription of ACE inhibitors/angiotensin receptor blockers/non-steroidal anti-inflammatory drugs/immunosuppressants; smoking status; Clinical Frailty Score (CFS); length of hospital stay; mortality and readmission. All patients receiving inpatient hospital care >18 years who receive a diagnosis of COVID-19 are eligible for inclusion. Long-term follow-up at 6 and 12 months is planned. This will assess frailty, quality of life and medical complications.Our primary analysis will be short-term and long-term mortality by CFS, adjusted for age (18-64, 65-80 and >80) and gender. We will carry out a secondary analysis of the primary outcome by including additional clinical mediators which are determined statistically important using a likelihood ratio test. All analyses will be presented as crude and adjusted HR and OR with associated 95% CIs and p values.

Ethics And Dissemination: This study has been registered, reviewed and approved by the following: Health Research Authority (20/HRA1898); Ethics Committee of Hospital Policlinico Modena, Italy (369/2020/OSS/AOUMO); Health and Care Research Permissions Service, Wales; and NHS Research Scotland Permissions Co-ordinating Centre, Scotland. All participating units obtained approval from their local Research and Development department consistent with the guidance from their relevant national organisation.Data will be reported as a whole cohort. This project will be submitted for presentation at a national or international surgical and geriatric conference. Manuscript(s) will be prepared following the close of the project.
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http://dx.doi.org/10.1136/bmjopen-2020-040569DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526029PMC
September 2020

How do anaesthetist and geriatrician perioperative frailty assessments compare?

Br J Anaesth 2020 12 25;125(6):e462-e463. Epub 2020 Sep 25.

Department of Anaesthesia, Southmead Hospital, Bristol, UK.

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http://dx.doi.org/10.1016/j.bja.2020.08.043DOI Listing
December 2020

The Clinical Frailty Scale predicts adverse outcome in older people admitted to a UK major trauma centre.

Age Ageing 2021 05;50(3):891-897

Consultant Physician and Perioperative Geriatrician, North Bristol NHS Trust, Bristol, UK.

Background: Frailty assessment using the Clinical Frailty Scale (CFS) has been mandated for older people admitted to English major trauma centres (MTC) since April 2019. Little evidence is available as to CFS-associated outcomes in the trauma population.

Objective: To investigate post-injury outcomes stratified by the CFS.

Methods: A single centre prospective observational cohort study was undertaken. CFS was prospectively assigned to patients ≥ 65 years old admitted to the MTC over a 5-month period. Primary outcome was 30-day post-injury mortality. Secondary outcomes were length of hospital stay, complications and discharge level of care.

Results: In 300 patients median age was 82; 146 (47%) were frail (CFS 5-9) and 28 (9.3%) severely frail (CFS 7-9). Frail patients had lower injury severity scores (median 9 vs 16) but greater 30-day mortality (CFS 5-6 odds ratio (OR) 5.68; P < 0.01; CFS 7-9 OR 10.38; P < 0.01). Frailty was associated with delirium (29.5% vs 17.5%; P = 0.02), but not complication rate (50.7% vs 41.6%; P = 0.20) or length of hospital stay (13 vs 11 days; P = 0.35). Mild to moderate frailty was associated with increased care level at discharge (OR 2.31; P < 0.01).

Conclusions: Frailty is an independent predictor of 30-day mortality, inpatient delirium and increased care level at discharge in older people experiencing trauma. CFS can therefore be used to identify those at risk of poor outcome who may benefit from comprehensive geriatric review, validating its inclusion in the 2019 best practice tariff for major trauma.
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http://dx.doi.org/10.1093/ageing/afaa180DOI Listing
May 2021

British Geriatric Society position statement: older patients undergoing emergency laparotomy.

Age Ageing 2021 01;50(1):268-269

Department of Ageing and Complex Medicine, Salford Royal NHS Foundation Trust, Salford, UK, & British Geriatrics Society representative to NELA Clinical Research Group.

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http://dx.doi.org/10.1093/ageing/afaa172DOI Listing
January 2021

Prior Routine Use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Important Outcomes in Hospitalised Patients with COVID-19.

J Clin Med 2020 Aug 10;9(8). Epub 2020 Aug 10.

Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, Scotland, UK.

Coronavirus disease 2019 (COVID-19) infection causes acute lung injury, resulting from aggressive inflammation initiated by viral replication. There has been much speculation about the potential role of non-steroidal inflammatory drugs (NSAIDs), which increase the expression of angiotensin-converting enzyme 2 (ACE2), a binding target for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to enter the host cell, which could lead to poorer outcomes in COVID-19 disease. The aim of this study was to examine the association between routine use of NSAIDs and outcomes in hospitalised patients with COVID-19. This was a multicentre, observational study, with data collected from adult patients with COVID-19 admitted to eight UK hospitals. Of 1222 patients eligible to be included, 54 (4.4%) were routinely prescribed NSAIDs prior to admission. Univariate results suggested a modest protective effect from the use of NSAIDs, but in the multivariable analysis, there was no association between prior NSAID use and time to mortality (adjusted HR (aHR) = 0.89, 95% CI 0.52-1.53, = 0.67) or length of stay (aHR 0.89, 95% CI 0.59-1.35, = 0.58). This study found no evidence that routine NSAID use was associated with higher COVID-19 mortality in hospitalised patients; therefore, patients should be advised to continue taking these medications until further evidence emerges. Our findings suggest that NSAID use might confer a modest benefit with regard to survival. However, as this finding was underpowered, further research is required.
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http://dx.doi.org/10.3390/jcm9082586DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7465199PMC
August 2020

The effect of frailty on survival in patients with COVID-19 (COPE): a multicentre, European, observational cohort study.

Lancet Public Health 2020 08 30;5(8):e444-e451. Epub 2020 Jun 30.

Department of Surgery and Care of the Elderly, Southmead Hospital, North Bristol NHS Trust, Bristol, UK. Electronic address:

Background: The COVID-19 pandemic has placed unprecedented strain on health-care systems. Frailty is being used in clinical decision making for patients with COVID-19, yet the prevalence and effect of frailty in people with COVID-19 is not known. In the COVID-19 in Older PEople (COPE) study we aimed to establish the prevalence of frailty in patients with COVID-19 who were admitted to hospital and investigate its association with mortality and duration of hospital stay.

Methods: This was an observational cohort study conducted at ten hospitals in the UK and one in Italy. All adults (≥18 years) admitted to participating hospitals with COVID-19 were included. Patients with incomplete hospital records were excluded. The study analysed routinely generated hospital data for patients with COVID-19. Frailty was assessed by specialist COVID-19 teams using the clinical frailty scale (CFS) and patients were grouped according to their score (1-2=fit; 3-4=vulnerable, but not frail; 5-6=initial signs of frailty but with some degree of independence; and 7-9=severe or very severe frailty). The primary outcome was in-hospital mortality (time from hospital admission to mortality and day-7 mortality).

Findings: Between Feb 27, and April 28, 2020, we enrolled 1564 patients with COVID-19. The median age was 74 years (IQR 61-83); 903 (57·7%) were men and 661 (42·3%) were women; 425 (27·2%) had died at data cutoff (April 28, 2020). 772 (49·4%) were classed as frail (CFS 5-8) and 27 (1·7%) were classed as terminally ill (CFS 9). Compared with CFS 1-2, the adjusted hazard ratios for time from hospital admission to death were 1·55 (95% CI 1·00-2·41) for CFS 3-4, 1·83 (1·15-2·91) for CFS 5-6, and 2·39 (1·50-3·81) for CFS 7-9, and adjusted odds ratios for day-7 mortality were 1·22 (95% CI 0·63-2·38) for CFS 3-4, 1·62 (0·81-3·26) for CFS 5-6, and 3·12 (1·56-6·24) for CFS 7-9.

Interpretation: In a large population of patients admitted to hospital with COVID-19, disease outcomes were better predicted by frailty than either age or comorbidity. Our results support the use of CFS to inform decision making about medical care in adult patients admitted to hospital with COVID-19.

Funding: None.
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http://dx.doi.org/10.1016/S2468-2667(20)30146-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7326416PMC
August 2020

Frailty in perioperative medicine.

Br J Hosp Med (Lond) 2019 Jun;80(6):357

Consultant Geriatrician, Department of Ageing and Health, Guys and St Thomas' NHS Foundation Trust, London.

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http://dx.doi.org/10.12968/hmed.2019.80.6.357DOI Listing
June 2019

Collaborative working: who is responsible?

Future Healthc J 2017 Jun;4(2):138-141

Guy's and St Thomas' Hospital, London, UK and Division of Health and Social Care Research, Kings College London, London, UK.

As delivery of healthcare becomes more complex, there is an increasing need for collaborative working between specialty teams. Recognition of this need has led to new models of care, for example surgeons, anaesthetists and geriatricians working together in the perioperative pathway. Although there is emerging evidence that these collaborative approaches are effective, there is little guidance on who is responsible for the patient throughout the healthcare episode. Government policy and legislation has increasingly focused on the need for a single named clinician to be responsible for the entirety of a patient's episode of care, with overall liability resting with the hospital trust as the provider organisation. This discrepancy between delivery of healthcare by teams and responsibility resting with an individual raises questions: how can clinicians and hospital trusts ensure synergistic patient care while maintaining clear lines of responsibility? Who should provide information to patients throughout the pathway? Who should the patient expect to be the point of contact? This dichotomy emphasises the need for new guidance to support the patient, the clinician and the provider organisation as shared models of care evolve and become embedded into routine practice.
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http://dx.doi.org/10.7861/futurehosp.4-2-138DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6502614PMC
June 2017

Evaluation and establishment of a ward-based geriatric liaison service for older urological surgical patients: Proactive care of Older People undergoing Surgery (POPS)-Urology.

BJU Int 2017 07 4;120(1):123-129. Epub 2016 Jun 4.

Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK.

Objective: To assess the impact of introducing and embedding a structured geriatric liaison service, Proactive care of Older People undergoing Surgery (POPS)-Urology, using comprehensive geriatric assessment methodology, on an inpatient urology ward.

Patients And Methods: A phased quality improvement project was undertaken using stepwise interventions. Phase 1 was a before-and-after study with initiation of a daily board round, weekly multidisciplinary meeting, and targeted geriatrician-led ward rounds for elective and emergency urology patients aged ≥65 years admitted over two 1-month periods. Outcomes were recorded from medical records and discharge documentation, including length of inpatient stay, medical and surgical complications, and 30-day readmission and mortality rates. Phase 2 was a quality improvement project involving Plan-Do-Study-Act cycles and qualitative staff surveys in order to create a Geriatric Surgical Checklist (GSCL) to standardize the intervention in Phase 1, improve equity of care by extending it to all ages, improve team-working and streamline handovers for multidisciplinary staff.

Results: Phase 1 included 112 patients in the control month and 130 in the intervention month. The length of inpatient stay was reduced by 19% (mean 4.9 vs 4.0 days; P = 0.01), total postoperative complications were lower (risk ratio 0.24 [95% confidence interval 0.10, 0.54]; P = 0.001). A non-significant trend was seen towards fewer cancellations of surgery (10 vs 5%; P = 0.12) and 30-day readmissions (8 vs 3%; P = 0.07). In Phase 2, the GSCL was created and incrementally improved. Questionnaires repeated at intervals showed that the GSCL helped staff to understand their role better in multidisciplinary meetings, improved their confidence to raise issues, reduced duplication of handovers and standardized identification of geriatric issues. Equity of care was improved by providing the intervention to patients of all ages, despite which the time taken for the daily board round did not lengthen.

Conclusion: This is the first known paper describing the benefits of daily proactive geriatric intervention in elective and emergency urological surgery. The results suggest that using a multidisciplinary team board round helps to facilitate collaborative working between surgical and geriatric medicine teams. The GSCL enables systematic identification of patients who require a focused comprehensive geriatric assessment. There is potential to transfer the GSCL package to other surgical specialties and hospitals to improve postoperative outcomes.
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http://dx.doi.org/10.1111/bju.13526DOI Listing
July 2017

Perioperative medicine for older patients: how do we deliver quality care?

Future Hosp J 2016 Feb;3(1):33-36

Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK; and Division of Health and Social Care Research, Kings College London, UK.

The demand for surgical intervention in older people is rising due to the growing older population with multimorbidity. Yet older people continue to have reduced access to surgery and have more adverse postoperative outcomes than younger people. Current models of preoperative risk assessment and optimisation are poorly suited to this complex surgical population. Furthermore, there has been little emphasis on perioperative management of older people in national anaesthetic and surgical curriculums. New models of care and training in perioperative medicine for older people are evolving, with national reports calling for collaboration between geriatricians, general physicians, anaesthetists and surgeons. Such collaboration is necessary to impact clinical service development, research agendas and education and training. In this article, we discuss the challenges and potential solutions in the establishment of quality surgical care for older people.
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http://dx.doi.org/10.7861/futurehosp.3-1-33DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6465847PMC
February 2016

Evaluation of a simulation training programme for geriatric medicine.

Age Ageing 2015 Jul 6;44(4):677-82. Epub 2015 May 6.

Department of Ageing and Health, Guy's and St Thomas' Hospital, Westminster Bridge Road, London, UK.

Background: geriatrics encompasses diverse medical, social and ethical challenges requiring a multidimensional, interdisciplinary approach. Recent reports have highlighted failings in the care of older people. It is therefore vital that trainees in geriatrics are afforded opportunities to develop skills in managing this complex population. Simulation has been adopted as a teaching tool in medicine; however, evidence for its use in geriatrics has been limited to small, single-site studies primarily involving role-play or discrete clinical skills training.

Methods: a standardised, two centre, multimodal, interprofessional, geriatrics simulation training programme was developed using curriculum-mapped scenarios in which the patient perspective was central. Simulation techniques used included high-fidelity patient manikins, actors with integrated clinical skills using part-task trainers and role-play exercises. A mixed-methods evaluation was used to analyse data from participants before and after training.

Results: eighty-nine candidates attended 12 similar courses over 2 years. Thematic analysis of candidate feedback was supportive of simulation as a useful tool, with benefits for both technical and non-technical skills. Candidates commented that simulation was a valuable training modality addressing curriculum areas rarely taught formally including continence assessment, end-of-life decisions and multidisciplinary situations. Quantitative analysis of pre- and post-course questionnaires revealed a significant improvement of self-reported confidence in managing geriatric scenarios (mean improvement 11.5%; P < 0.001).

Discussion: this study demonstrated the feasibility of a standardised simulation training programme across two sites in geriatrics. Simulation training affords situational learning without compromising patient safety and is an exciting and novel method of delivering teaching for geriatrics that could be integrated into national training curricula.
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http://dx.doi.org/10.1093/ageing/afv049DOI Listing
July 2015

Embolization of pulmonary arteriovenous malformations using the Amplatzer vascular plug: successful treatment of 69 consecutive patients.

Eur Radiol 2010 Nov 24;20(11):2663-70. Epub 2010 Jun 24.

Department of Imaging, Imperial College Healthcare NHS Trust, London, England.

Objective: The technique of embolization of pulmonary arteriovenous malformations (PAVMs) with the Amplatzer vascular plug (AVP) has been reported, but no large series has evaluated the effectiveness of this relatively new embolic device. The purpose of this study is to assess the role of AVPs in the treatment of PAVMs.

Materials And Methods: Sixty-nine consecutive patients underwent embolization of pulmonary arteriovenous malformations between September 2006 and December 2008. Clinical, procedural, and physiological data were reviewed retrospectively.

Results: Of 161 PAVMs, 120 (75%) were successfully embolized with Amplatzer vascular plugs alone. Complete and rapid occlusion of feeding vessels was easily achieved at the site of arteriovenous communication without complication. Particularly small or tortuous feeding arteries supplying 27 complex and 14 simple PAVMs were occluded with coils. There have been no documented instances of recanalization on follow-up.

Conclusion: Amplatzer vascular plugs allow the rapid and safe distal occlusion of the majority of PAVMs.
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http://dx.doi.org/10.1007/s00330-010-1851-2DOI Listing
November 2010
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