Clinical Frailty Scale at presentation to the emergency department: interrater reliability and use of algorithm-assisted assessment

PURPOSE

The Clinical Frailty Scale (CFS) allows health care providers to quickly stratify older patients, to support clinical decision-making. However, few studies have evaluated the CFS interrater reliability (IRR) in Emergency Departments (EDs), and the freely available smartphone application for CFS assessment was never tested for reliability. This study aimed to evaluate the interrater reliability of the Clinical Frailty Scale (CFS) ratings between experienced and unexperienced staff (ED clinicians and a study team (ST) of medical students supported by a smartphone application to assess the CFS), and to determine the feasibility of CFS assignment in patients aged 65 or older at triage.

METHODS

Cross-sectional study using consecutive sampling of ED patients aged 65 or older. We compared assessments by ED clinicians (Triage Clinicians (TC) and geriatric ED trained nurses (geriED-TN)) and a study team (ST) of medical students using a smartphone application for CFS scoring. The study is registered on Clinicaltrials.gov (NCT05400707).

RESULTS

We included 1349 patients aged 65 and older. Quadratic-weighted kappa values for ordinal CFS levels showed a good IRR between TC and ST (ϰ = 0.73, 95% CI 0.69-0.76), similarly to that between TC and geriED-TN (ϰ = 0.75, 95% CI 0.66-0.82) and between the ST and geriED-TN (ϰ = 0.74, 95% CI 0.63-0.81). A CFS rating was assigned to 972 (70.2%) patients at triage.

CONCLUSION

We found good IRR in the assessment of frailty with the CFS in different ED providers and a team using a smartphone application to support rating. A CFS assessment occurred in more than two-thirds (70.2%) of patients at triage.

Measuring gut perfusion and blood flow in neonates using ultrasound Doppler of the superior mesenteric artery: a narrative review

The gut is a relatively silent organ in utero but takes on a major role after birth for the absorption and digestion of feed for adequate nutrition and growth. The neonatal circulation undergoes a transition period after birth, and gut perfusion increases rapidly to satisfy the oxygen demand and consumption. If this process is compromised at any stage, preterm and fetal growth restricted infants are at particular risk of gut tissue injury secondary to hypoxia, leading to necrotizing enterocolitis. Feeding can also be a challenge in these high-risk groups due to gut dysmotility. Superior mesenteric artery (SMA) Doppler is a safe, bedside investigation that could rapidly aid clinicians with feeding strategies and in monitoring high-risk infants. This article aims to establish normal patterns of gut blood flow velocity in neonates using SMA Doppler and reviews how it might be used clinically in pathologic states.

Variability of neonatal premedication practices for endotracheal intubation and LISA in the UK (NeoPRINT survey)

OBJECTIVE

The NeoPRINT Survey was designed to assess premedication practices throughout UK NHS Trusts for both neonatal endotracheal intubation and less invasive surfactant administration (LISA).

DESIGN

An online survey consisting of multiple choice and open answer questions covering preferences of premedication for endotracheal intubation and LISA was distributed over a 67-day period. Responses were then analysed using STATA IC 16.0.

SETTING

Online survey distributed to all UK Neonatal Units (NNUs).

PARTICIPANTS

The survey evaluated premedication practices for endotracheal intubation and LISA in neonates requiring these procedures.

MAIN OUTCOME MEASURES

The use of different premedication categories as well as individual medications within each category was analysed to create a picture of typical clinical practice across the UK.

RESULTS

The response rate for the survey was 40.8 % (78/191). Premedication was used in all hospitals for endotracheal intubation but overall, 50 % (39/78) of the units that have responded, use premedications for LISA. Individual clinician preference had an impact on premedication practices within each NNU.

CONCLUSION

The wide variability on first-line premedication for endotracheal intubation noted in this survey could be overcome using best available evidence through consensus guidance driven by organisations such as British Association of Perinatal |Medicine (BAPM). Secondly, the divisive view around LISA premedication practices noted in this survey requires an answer through a randomised controlled trial.

1146 SLEEP DEPRIVATION INDUCES AGEING-LIKE CHANGES IN ANTIGRAVITY MUSCLES OF YOUNG ADULT MALE WISTAR RATS

Introduction

Poor muscle health is associated with a series of chronic and metabolic conditions that are prevalent in individuals who chronically experience poor-quality sleep. But there is no study deciphering the role of sleep deprivation on muscle ageing. Therefore, in the present study we have measured the ultrastructure, histopathology, and oxidative stressors in soleus muscle of wistar rat after sleep deprivation and recovery sleep.

Material and Methods

The experiments were conducted in 18 rats of three groups. Group I rats had normal sleep wake cycle, Group II rats were subjected to 24 h sleep deprivation (SD) by gentle handling method1 and Group III rats had recovery sleep after 24 h SD. At the end of the sleep, sleep deprivation and recovery period, soleus muscle tissue was collected for ultrastructural, histological and oxidative stress markers. Oxidative damage was assessed by lipid peroxidation, catalase activity, reduced glutathione and nuclear labelling of 8-OHdG. The study was conducted as per the guidelines of the Institutional Animal Ethics Committee (960/IAEC/16).

Results

The data demonstrated that SD leads to ultrastructural changes in soleus muscle which includes sarcolemmal and mitochondrial alterations. In case of histopathological and histomorphological changes there was signs of tissue degeneration, inflammatory infiltrate in type I fibres and muscle atrophy was observed in soleus muscles. There was significant increase in level of 8-OHdG (p=0.02) and malondialdehyde in 24h SD (p=0.02) than control and recovery sleep groups. Moreover, the catalase activity and reduced glutathione level was significantly decreased in 24h SD group (p≤0.02) than control and recovery sleep.

Conclusion

24hr sleep deprivation leads to an ageing like state in the skeletal muscle, which was recovered after sleep rebound.

A comparison between the clinical frailty scale and the hospital frailty risk score to risk stratify older people with emergency care needs

BACKGROUND

Older adults living with frailty who require treatment in hospitals are increasingly seen in the Emergency Departments (EDs). One quick and simple frailty assessment tool-the Clinical Frailty Scale (CFS)-has been embedded in many EDs in the United Kingdom (UK). However, it carries time/training and cost burden and has significant missing data. The Hospital Frailty Risk Score (HFRS) can be automated and has the potential to reduce costs and increase data availability, but has not been tested for predictive accuracy in the ED. The aim of this study is to assess the correlation between and the ability of the CFS at the ED and HFRS to predict hospital-related outcomes.

METHODS

This is a retrospective cohort study using data from Leicester Royal Infirmary hospital during the period from 01/10/2017 to 30/09/2019. We included individuals aged + 75 years as the HFRS has been only validated for this population. We assessed the correlation between the CFS and HFRS using Pearson's correlation coefficient for the continuous scores and weighted kappa scores for the categorised scores. We developed logistic regression models (unadjusted and adjusted) to estimate Odds Ratios (ORs) and Confidence Intervals (CIs), so we can assess the ability of the CFS and HFRS to predict 30-day mortality, Length of Stay (LOS) > 10 days, and 30-day readmission.

RESULTS

Twelve thousand two hundred thirty seven individuals met the inclusion criteria. The mean age was 84.6 years (SD 5.9) and 7,074 (57.8%) were females. Between the CFS and HFRS, the Pearson correlation coefficient was 0.36 and weighted kappa score was 0.15. When comparing the highest frailty categories to the lowest frailty category within each frailty score, the ORs for 30-day mortality, LOS > 10 days, and 30-day readmission using the CFS were 2.26, 1.36, and 1.64 and for the HFRS 2.16, 7.68, and 1.19.

CONCLUSION

The CFS collected at the ED and the HFRS had low/slight agreement. Both frailty scores were shown to be predictors of adverse outcomes. More research is needed to assess the use of historic HFRS in the ED.

Pregnancy and neonatal outcomes of COVID-19: The PAN-COVID study

OBJECTIVE

To assess perinatal outcomes for pregnancies affected by suspected or confirmed SARS-CoV-2 infection.

METHODS

Prospective, web-based registry. Pregnant women were invited to participate if they had suspected or confirmed SARS-CoV-2 infection between 1st January 2020 and 31st March 2021 to assess the impact of infection on maternal and perinatal outcomes including miscarriage, stillbirth, fetal growth restriction, pre-term birth and transmission to the infant.

RESULTS

Between April 2020 and March 2021, the study recruited 8239 participants who had suspected or confirmed SARs-CoV-2 infection episodes in pregnancy between January 2020 and March 2021. Maternal death affected 14/8197 (0.2%) participants, 176/8187 (2.2%) of participants required ventilatory support. Pre-eclampsia affected 389/8189 (4.8%) participants, eclampsia was reported in 40/ 8024 (0.5%) of all participants. Stillbirth affected 35/8187 (0.4 %) participants. In participants delivering within 2 weeks of delivery 21/2686 (0.8 %) were affected by stillbirth compared with 8/4596 (0.2 %) delivering ≥ 2 weeks after infection (95 % CI 0.3-1.0). SGA affected 744/7696 (9.3 %) of livebirths, FGR affected 360/8175 (4.4 %) of all pregnancies. Pre-term birth occurred in 922/8066 (11.5%), the majority of these were indicated pre-term births, 220/7987 (2.8%) participants experienced spontaneous pre-term births. Early neonatal deaths affected 11/8050 livebirths. Of all neonates, 80/7993 (1.0%) tested positive for SARS-CoV-2.

CONCLUSIONS

Infection was associated with indicated pre-term birth, most commonly for fetal compromise. The overall proportions of women affected by SGA and FGR were not higher than expected, however there was the proportion affected by stillbirth in participants delivering within 2 weeks of infection was significantly higher than those delivering ≥ 2 weeks after infection. We suggest that clinicians' threshold for delivery should be low if there are concerns with fetal movements or fetal heart rate monitoring in the time around infection. The proportion affected by pre-eclampsia amongst participants was not higher than would be expected, although we report a higher than expected proportion affected by eclampsia. There appears to be no effect on birthweight or congenital malformations in women affected by SARS-CoV-2 infection in pregnancy and neonatal infection is uncommon. This study reflects a population with a range of infection severity for SARS-COV-2 in pregnancy, generalisable to whole obstetric populations.

Prevalence and molecular characterization of extended-spectrum β-lactamase (ESBL) producing Escherichia coli isolated from dogs suffering from diarrhea in and around Kolkata

BACKGROUND

Dogs are the favorite companion animals among humans. The close interaction between dogs and people increases the risk of antibiotic resistance spreading. Surveillance for antimicrobial resistance and the identification of ESBL-producing Escherichia coli as an indicator bacterium is an important tool for managing antimicrobial drug therapy.

AIMS

The present study targeted to identify and characterize ESBL-producing E. coli among dogs suffering from diarrhea in and around Kolkata.

METHODS

Isolation and identification of E. coli from dogs suffering from diarrhea (n=70) along with screening for the production of both ESBL and AmpC. The isolates were further characterized through antimicrobial resistance profiling, resistance genes (bla _CTX-M, bla _TEM, and bla _SHV) screening, and phylogenetic group study.

RESULTS

Among the 70 isolates, 21 (30%) were confirmed ESBL producers. An antibiogram typing of ESBL-producing E. coli revealed that the majority of them were resistant to norfloxacin (85.7%) followed by tetracycline (61.90%), doxycycline (57.14%), piperacillin/tazobactam (52.38%), cotrimoxazole (47.62%), gentamicin (42.62%), amikacin (23.81%), and chloramphenicol (19.05%). Major resistance genes included bla _CTX-M (100%), bla _TEM (28.57%), and bla _SHV (9.50%). The predominant phylogenetic groups were phylogroup A (76%) followed by phylogroup D (24%).

CONCLUSION

The current investigation reported a high prevalence of both ESBL and AmpC β-lactamase (AmpC) producing E. coli, co-resistance to a distinct group of antibiotics, and co-existence of different ESBL genes in dogs. Our findings highlight the importance of diagnostic antimicrobial susceptibility testing for proper antimicrobial therapy and to prevent antimicrobial resistance from spreading to humans from dogs in Kolkata and the surrounding area.

Association between frailty and C-terminal agrin fragment with 3-month mortality following ST-elevation myocardial infarction

The objective of this study was to evaluate the association between frailty, evaluated by the Clinical Frailty Scale (CFS) and FRAIL scale, and C-terminal agrin fragment (CAF) levels with 3-month mortality following ST-segment elevation myocardial infarction (STEMI). This was a prospective observational study that included patients over the age of 18 years with STEMI admitted to the coronary intensive care unit. Within 48 h of admission, the CFS and FRAIL scale were applied and blood samples collected for serum CAF evaluation. Patients were followed for 3 months after hospital discharge, and mortality was recorded. One hundred and eleven patients were included; mean age was 62.3 ± 12.4 years, 61.3% were male and 11.7% died during the 3 months of follow-up. According to the CFS, 79.3% of the patients were classified as not frail, 12.6% as pre-frail and 8.1% as frail. According to the FRAIL scale, 31.5% of the patients were classified as not frail, 53.2% as pre-frail and 15.3% as frail. In univariate analysis, the CFS but not FRAIL scale was associated with mortality. In multiple logistic regression analysis, pre-frail/frail according to CFS (odds ratio [OR]: 6.118; CI 95%: 1.344-27.848; p = 0.019) and CAF levels (OR: 0.943; CI 95%: 0.896-0.992; p = 0.024) were associated with increased 3-month mortality. In a sub-analysis of 53 patients ≥65 years, CFS and CAF levels were associated with 3-month mortality. In conclusion, CAF levels and frailty determined by the CFS were associated with 3-month mortality after STEMI in the general and older population.

Current perspectives on defining and mitigating frailty in relation to critical illness

Up to half of ICU survivors, many of whom were premorbidly well, will have residual functional and/or cognitive impairment and be vulnerable to future health problems. Frailty describes vulnerability to poor resolution of homeostasis after a stressor event but it is not clear whether the vulnerability seen after ICU correlates with clinical measures of frailty. In clinical practice, the scales most commonly used in critically ill patients are based on the assessment of severity and survival. Identification and monitoring of frailty in the ICU may be an alternative or complimentary approach, particularly if it helps explain vulnerability during the recovery and rehabilitation period. The purpose of this review is to discuss the use of tools to assess frailty status in the critically ill, and consider their importance in clinical practice. Amongst these, we consider biomarkers with potential to identify patients at greater or lesser risk of developing post-ICU vulnerability.

Talking about frailty: The role of stigma and precarity in older peoples' constructions of frailty

The clinical identification of frailty is increasingly thought to be important in countries with ageing populations. Understanding how older people labelled as frail make sense of this categorisation is therefore important. A number of recent studies have reported negative perceptions of the term among older people themselves. Building on this, we focus on how and why those assessed to be frail make sense of frailty as they do. We draw on 26a discourse analysis of situated interviews with 30 older people accessing emergency care in an English NHS hospital. Three interpretive repertoire pairs (Frailty is 26a bodily issue/frailty is about mind-set; Frailty is 26a negative experience/frailty is an inevitable experience; I'm not frail/I feel frail), identified across the participants' talk, are outlined and discussed in relation to discourses of the fourth age and precarity. We conclude that frailty is often seen in terms what others have referred to as 'real' old age and is linked to discourses of dependence and precarity.

How quality improvement collaboratives work to improve healthcare in care homes: a realist evaluation

BACKGROUND

Quality improvement collaboratives (QICs) bring together multidisciplinary teams in a structured process to improve care quality. How QICs can be used to support healthcare improvement in care homes is not fully understood.

METHODS

A realist evaluation to develop and test a programme theory of how QICs work to improve healthcare in care homes. A multiple case study design considered implementation across 4 sites and 29 care homes. Observations, interviews and focus groups captured contexts and mechanisms operating within QICs. Data analysis classified emerging themes using context-mechanism-outcome configurations to explain how NHS and care home staff work together to design and implement improvement.

RESULTS

QICs will be able to implement and iterate improvements in care homes where they have a broad and easily understandable remit; recruit staff with established partnership working between the NHS and care homes; use strategies to build relationships and minimise hierarchy; protect and pay for staff time; enable staff to implement improvements aligned with existing work; help members develop plans in manageable chunks through QI coaching; encourage QIC members to recruit multidisciplinary support through existing networks; facilitate meetings in care homes and use shared learning events to build multidisciplinary interventions stepwise. Teams did not use measurement for change, citing difficulties integrating this into pre-existing and QI-related workload.

CONCLUSIONS

These findings outline what needs to be in place for health and social care staff to work together to effect change. Further research needs to consider ways to work alongside staff to incorporate measurement for change into QI.

Frailty as biographical disruption

Biographical disruption positions the onset of chronic illness as a major life disruption in which changes to body, self and resources occur (Sociology of Health & Illness, 4, 1982, 167-182). The concept has been used widely in medical sociology. It has also been subject to critique and development by numerous scholars. In this paper, we build on recent developments of the concept, particularly those taking a phenomenological approach, to argue that it can also help in understanding other disruptive health-related experiences across the life course, in this case the onset of frailty. We draw on the findings of 30 situated interviews with frail older people, relating their experiences of frailty to the concept of biographical disruption. We show that frailty shares many similarities with the experience of chronic illness. Using the lens of biographical disruption to understand frailty also offers insights relevant to recent debates around both concepts, and on the continued relevance of the idea of biographical disruption given changing experiences of health and illness, including the circumstances in which biographical disruption is more and less likely to be experienced. Finally, we reflect on the potentials and limitations of applying the concept to a health-related condition that cannot be categorised as a disease.

Emergency department management of older people living with frailty: a guide for emergency practitioners

Emergency Departments (EDs) are increasingly seeing more seriously unwell older people living with frailty. In the context of limited resources and increasing demand it's the ED practitioner's challenge to unpick this constellation of physical, psychological, functional and social issues.To properly assess older people living with frailty at the ED it is crucial to use an holistic approach. This consists of triage with algorithms sensitive to the higher risk of older people living with frailty, a frailty assessment, and an assessment with the help of the principles of Comprehensive Geriatric Assessment. Multi-disciplinary care, a tailor-made treatment plan, based on what the person values most, will help the ED practitioner to deliver appropriate and valuable care during the ED stay, but also in transition from hospital to home.

Pregnancy and neonatal outcomes of COVID-19: coreporting of common outcomes from PAN-COVID and AAP-SONPM registries

OBJECTIVE

Few large cohort studies have reported data on maternal, fetal, perinatal and neonatal outcomes associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnancy. We report the outcome of infected pregnancies from a collaboration formed early during the pandemic between the investigators of two registries, the UK and Global Pregnancy and Neonatal outcomes in COVID-19 (PAN-COVID) study and the American Academy of Pediatrics (AAP) Section on Neonatal-Perinatal Medicine (SONPM) National Perinatal COVID-19 Registry.

METHODS

This was an analysis of data from the PAN-COVID registry (1 January to 25 July 2020), which includes pregnancies with suspected or confirmed maternal SARS-CoV-2 infection at any stage in pregnancy, and the AAP-SONPM National Perinatal COVID-19 registry (4 April to 8 August 2020), which includes pregnancies with positive maternal testing for SARS-CoV-2 from 14 days before delivery to 3 days after delivery. The registries collected data on maternal, fetal, perinatal and neonatal outcomes. The PAN-COVID results are presented overall for pregnancies with suspected or confirmed SARS-CoV-2 infection and separately in those with confirmed infection.

RESULTS

We report on 4005 pregnant women with suspected or confirmed SARS-CoV-2 infection (1606 from PAN-COVID and 2399 from AAP-SONPM). For obstetric outcomes, in PAN-COVID overall and in those with confirmed infection in PAN-COVID and AAP-SONPM, respectively, maternal death occurred in 0.5%, 0.5% and 0.2% of cases, early neonatal death in 0.2%, 0.3% and 0.3% of cases and stillbirth in 0.5%, 0.6% and 0.4% of cases. Delivery was preterm (< 37 weeks' gestation) in 12.0% of all women in PAN-COVID, in 16.1% of those women with confirmed infection in PAN-COVID and in 15.7% of women in AAP-SONPM. Extreme preterm delivery (< 27 weeks' gestation) occurred in 0.5% of cases in PAN-COVID and 0.3% in AAP-SONPM. Neonatal SARS-CoV-2 infection was reported in 0.9% of all deliveries in PAN-COVID overall, in 2.0% in those with confirmed infection in PAN-COVID and in 1.8% in AAP-SONPM; the proportions of neonates tested were 9.5%, 20.7% and 87.2%, respectively. The rates of a small-for-gestational-age (SGA) neonate were 8.2% in PAN-COVID overall, 9.7% in those with confirmed infection and 9.6% in AAP-SONPM. Mean gestational-age-adjusted birth-weight Z-scores were -0.03 in PAN-COVID and -0.18 in AAP-SONPM.

CONCLUSIONS

The findings from the UK and USA registries of pregnancies with SARS-CoV-2 infection were remarkably concordant. Preterm delivery affected a higher proportion of women than expected based on historical and contemporaneous national data. The proportions of pregnancies affected by stillbirth, a SGA infant or early neonatal death were comparable to those in historical and contemporaneous UK and USA data. Although maternal death was uncommon, the rate was higher than expected based on UK and USA population data, which is likely explained by underascertainment of women affected by milder or asymptomatic infection in pregnancy in the PAN-COVID study, although not in the AAP-SONPM study. The data presented support strong guidance for enhanced precautions to prevent SARS-CoV-2 infection in pregnancy, particularly in the context of increased risks of preterm delivery and maternal mortality, and for priority vaccination of pregnant women and women planning pregnancy. Copyright © 2021 ISUOG. Published by John Wiley & Sons Ltd.

New Horizons in Understanding Appropriate Prehospital Identification and Trauma Triage for Older Adults

Caring for older people is an important part of prehospital practice, including appropriate triage and transportation decisions. However, prehospital triage criteria are designed to predominantly assess injury severity or high-energy mechanism which is not the case for older people who often have injuries compounded by multimorbidity and frailty. This has led to high rates of under-triage in this population. This narrative review aimed to assess aspects other than triage criteria to better understand and improve prehospital triage decisions for older trauma patients. This includes integrating frailty assessment in prehospital trauma triage, which was shown to predict adverse outcomes for older trauma patients. Furthermore, determining appropriate outcome measures and the benefits of Major Trauma Centers (MTCs) for older trauma patients should be considered in order to direct accurate and more beneficial prehospital trauma triage decisions. It is still not clear what are the appropriate outcome measures that should be applied when caring for older trauma patients. There is also no strong consensus about the benefits of MTC access for older trauma patients with regards to survival, in-hospital length of stay, discharge disposition, and complications. Moreover, looking into factors other than triage criteria such as distance to MTCs, patient or relative choice, training, unfamiliarity with protocols, and possible ageism, which were shown to impact prehospital triage decisions but their impact on outcomes has not been investigated yet, should be more actively assessed and investigated for this population. Therefore, this paper aimed to discuss the available evidence around frailty assessment in prehospital care, appropriate outcome measures for older trauma patients, the benefits of MTC access for older patients, and factors other than triage criteria that could adversely impact accurate prehospital triage decisions for older trauma patients. It also provided several suggestions for the future.

Comparing associations between frailty and mortality in hospitalised older adults with or without COVID-19 infection: a retrospective observational study using electronic health records

BACKGROUND

The aim of this study was to describe outcomes in hospitalised older people with different levels of frailty and COVID-19 infection.

METHODS

We undertook a single-centre, retrospective cohort study examining COVID-19-related mortality using electronic health records, for older people (65 and over) with frailty, hospitalised with or without COVID-19 infection. Baseline covariates included demographics, early warning scores, Charlson Comorbidity Indices and frailty (Clinical Frailty Scale, CFS), linked to COVID-19 status.

FINDINGS

We analysed outcomes on 1,071 patients with COVID-19 test results (285 (27%) were positive for COVID-19). The mean age at ED arrival was 79.7 and 49.4% were female. All-cause mortality (by 30 days) rose from 9 (not frail) to 33% (severely frail) in the COVID-negative cohort but was around 60% for all frailty categories in the COVID-positive cohort. In adjusted analyses, the hazard ratio for death in those with COVID-19 compared to those without COVID-19 was 7.3 (95% CI: 3.00, 18.0) with age, comorbidities and illness severity making small additional contributions.

INTERPRETATION

In this study, frailty measured using the CFS appeared to make little incremental contribution to the hazard of dying in older people hospitalised with COVID-19 infection; illness severity and comorbidity had a modest association with the overall adjusted hazard of death, whereas confirmed COVID-19 infection dominated, with a sevenfold hazard for death.

Does the Clinical Frailty Scale at Triage Predict Outcomes From Emergency Care for Older People?

STUDY OBJECTIVE

We determine whether the Clinical Frailty Scale applied at emergency department (ED) triage is associated with important service- and patient-related outcomes.

METHODS

We undertook a single-center, retrospective cohort study examining hospital-related outcomes and their associations with frailty scores assessed at ED triage. Participants were aged 65 years or older, registered on their first ED presentation during the study period at a single, centralized ED in the United Kingdom. Baseline data included age, sex, Clinical Frailty Scale score, National Early Warning Score-2 and the Charlson Comorbidity Index score; outcomes included length of stay, readmissions (any future admissions), and mortality (inhospital or out of hospital) up to 2 years after ED presentation. Survival analysis methods (standard and competing risks) were applied to assess associations between ED triage frailty scores and outcomes. Unadjusted incidence curves and adjusted hazard ratios are presented.

RESULTS

A total of 52,562 individuals representing 138,328 ED attendances were included; participants' mean age was 78.0 years, and 55% were women. Initial admission rates generally increased with frailty. Mean length of stay after 30- or 180-day follow-up was relatively low; all Clinical Frailty Scale categories included patients who experienced zero days' length of stay (ie, ambulatory care) and patients with relatively high numbers of inhospital days. Overall, 46% of study participants were readmitted by the 2-year follow-up. Readmissions increased with Clinical Frailty Scale score up until a score of 6 and then attenuated. Mortality rates increased with increasing frailty; the adjusted hazard ratio was 3.6 for Clinical Frailty Scale score 7 to 8 compared with score 1 to 3.

CONCLUSION

Frailty assessed at ED triage (with the Clinical Frailty Scale) is associated with adverse outcomes in older people. Its use in ED triage might aid immediate clinical decisionmaking and service configuration.

Quality improvement in long-term care settings: a scoping review of effective strategies used in care homes

PURPOSE

We conducted a scoping review of quality improvement in care homes. We aimed to identify participating occupational groups and methods for evaluation. Secondly, we aimed to describe resident-level interventions and which outcomes were measured.

METHODS

Following extended PRISMA guideline for scoping reviews, we conducted systematic searches of Medline, CINAHL, Psychinfo, and ASSIA (2000-2019). Furthermore, we searched systematic reviews databases including Cochrane Library and JBI, and the grey literature database, Greylit. Four co-authors contributed to selection and data extraction.

RESULTS

Sixty five studies were included, 6 of which had multiple publications (75 articles overall). A range of quality improvement strategies were implemented, including audit feedback and quality improvement collaboratives. Methods consisted of controlled trials, quantitative time series and qualitative interview and observational studies. Process evaluations, involving staff of various occupational groups, described experiences and implementation measures. Many studies measured resident-level outputs and health outcomes. 14 studies reported improvements to a clinical measure; however, four of these articles were of low quality. Larger randomised controlled studies did not show statistically significant benefits to resident health outcomes.

CONCLUSION

In care homes, quality improvement has been applied with several different strategies, being evaluated by a variety of measures. In terms of measuring benefits to residents, process outputs and health outcomes have been reported. There was no pattern of which quality improvement strategy was used for which clinical problem. Further development of reporting of quality improvement projects and outcomes could facilitate implementation.

A consensus building exercise to determine research priorities for silver trauma

BACKGROUND

Emergency care research into 'Silver Trauma', which is simply defined as major trauma consequent upon relatively minor injury mechanisms, is facing many challenges including that at present, there is no clear prioritisation of the issues. This study aimed to determine the top research priorities to guide future research.

METHODS

This consensus-based prioritization exercise used a three-stage modified Delphi technique. The study consisted of an idea generating (divergent) first round, a ranking evaluation in the second round, and a (convergent) consensus meeting in the third round.

RESULTS

A total of 20 research questions advanced to the final round of this study. After discussing the importance and clinical significance of each research question, five research questions were prioritised by the experts; the top three research priorities were: (1). What are older people's preferred goals of trauma care? (2). Beyond the Emergency Department (ED), what is the appropriate combined geriatric and trauma care? (3). Do older adults benefit from access to trauma centres? If so, do older trauma patients have equitable access to trauma centre compared to younger adults?

CONCLUSION

The results of this study will assist clinicians, researchers, and organisations that are interested in silver trauma in guiding their future efforts and funding toward addressing the identified research priorities.

032 Clinical frailty score as a decision-making tool in the emergency department – a step towards better outcomes for older patients

Background

The ≥65 year age group don’t always receive appropriate emergency care, occasionally due to ageism and as the ‘medical’ model of emergency care often does not benefit frail older patients.

Over a six month period from December ’18 - June ’19, as part of a LeicGEM initiative, we aimed to:

1. Improve accurate calculation and documentation of the CFS for patients ≥65 years.

2. Increase utilisation of the CFS in providing individualised and holistic care for patients with frailty i.e. CFS ≥5.

3. Improve consideration of end-of-life care (EOLC) if CFS ≥7.

Through monthly PDSA cycles, our frailty QI team introduced interventions including: info-posters disseminated through email, handover sessions, ‘Champions’ on the shop-floor, targeted educational sessions and leaflets. We utilised rapid-cycle audit information and staff perceptions survey to measure improvements and focus initiatives. In the last 6 weeks, we looked for sustainability of improvements.

CFS documentation improved and remained accurate, which was sustained. Discussions with patients and families, and ‘thought’ given to offer holistic, individualised care both showed improvement, though this was not definitely sustained. EOLC discussions did not show any definite improvement.

Frailty is a clinically important entity that is recognisable and accurately measurable by emergency physicians. If appropriately used, the CFS can help guide clinical care plans for patients.

Simple interventions in a local ED setting were able to improve documentation and utilisation of the CFS to provide patient-centred care for older patients.

Changing to a culture more open to EOLC discussions in the emergency setting was noted to be difficult both from our staff survey and audit data. This will need a more focused approach to improve departmental culture to have, and staff comfort to start an EOLC conversation.

We will continue to advocate for use of CFS, and for better care for all our older patients.

Abstract 032 Figure 1

CFS completion runchart

Abstract 032 Figure 2

EOLC runchart

Abstract 032 Figure 3

Individualised care runchart

Concepts in Practice: Geriatric Emergency Departments

In 2018, the American College of Emergency Physicians (ACEP) began accrediting facilities as "geriatric emergency departments" (EDs) according to adherence to the multiorganizational guidelines published in 2014. The guidelines were developed to help every ED improve its care of older adults. The geriatric ED guideline recommendations span the care continuum from out-of-hospital care, ED staffing, protocols, infrastructure, and transitions to outpatient care. Hospitals interested in making their EDs more geriatric friendly thus face the challenge of adopting, adapting, and implementing extensive guideline recommendations in a cost-effective manner and within the capabilities of their facilities and staff. Because all innovation is at heart local and must function within the constraints of local resources, different hospital systems have developed implementation processes for the geriatric ED guidelines according to their differing institutional capabilities and resources. This article describes 4 geriatric ED models of care to provide practical examples and guidance for institutions considering developing geriatric EDs: a geriatric ED-specific unit, geriatrics practitioner models, geriatric champions, and geriatric-focused observation units. The advantages and limitations of each model are compared and examples of specific institutions and their operational metrics are provided.

Understanding variation in unplanned admissions of people aged 85 and over: a systems-based approach

AIM

To examine system characteristics associated with variations in unplanned admission rates in those aged 85+.

DESIGN

Mixed methods.

SETTING

Primary care trusts in England were ranked according to changes in admission rates for people aged 85+ between 2007 and 2009, and study sites selected from each end of the distribution: three 'improving' sites where rates had declined by more than 4% and three 'deteriorating' sites where rates had increased by more than 20%. Each site comprised an acute hospital trust, its linked primary care trust/clinical commissioning group, the provider of community health services and adult social care.

PARTICIPANTS

A total of 142 representatives from these organisations were interviewed to understand how policies had been developed and implemented. McKinsey's 7S framework was used as a structure for investigation and analysis.

RESULTS

In general, improving sites provided more evidence of comprehensive system focused strategies backed by strong leadership, enabling the development and implementation of policies and procedures to avoid unnecessary admissions of older people. In these sites, primary and intermediate care services appeared more comprehensive and better integrated with other parts of the system, and policies in emergency departments were more focused on providing alternatives to admission.

CONCLUSIONS

Health and social care communities which have attenuated admissions of people aged 85+ prioritised developing a shared vision and strategy, with sustained implementation of a suite of interventions.

Accuracy of Dementia Screening Instruments in Emergency Medicine: A Diagnostic Meta-analysis

BACKGROUND

Dementia is underrecognized in older adult emergency department (ED) patients, which threatens operational efficiency, diagnostic accuracy, and patient satisfaction. The Society for Academic Emergency Medicine geriatric ED guidelines advocate dementia screening using validated instruments.

OBJECTIVES

The objective was to perform a systematic review and meta-analysis of the diagnostic accuracy of sufficiently brief screening instruments for dementia in geriatric ED patients. A secondary objective was to define an evidence-based pretest probability of dementia based on published research and then estimate disease thresholds at which dementia screening is most appropriate. This systematic review was registered with PROSPERO (CRD42017074855).

METHODS

PubMed, EMBASE, CINAHL, CENTRAL, DARE, and SCOPUS were searched. Studies in which ED patients ages 65 years or older for dementia were included if sufficient details to reconstruct 2 × 2 tables were reported. QUADAS-2 was used to assess study quality with meta-analysis reported if more than one study evaluated the same instrument against the same reference standard. Outcomes were sensitivity, specificity, and positive and negative likelihood ratios (LR+ and LR-). To identify test and treatment thresholds, we employed the Pauker-Kassirer method.

RESULTS

A total of 1,616 publications were identified, of which 16 underwent full text-review; nine studies were included with a weighted average dementia prevalence of 31% (range, 12%-43%). Eight studies used the Mini Mental Status Examination (MMSE) as the reference standard and the other study used the MMSE in conjunction with a geriatrician's neurocognitive evaluation. Blinding to the index test and/or reference standard was inadequate in four studies. Eight instruments were evaluated in 2,423 patients across four countries in Europe and North America. The Abbreviated Mental Test (AMT-4) most accurately ruled in dementia (LR+ = 7.69 [95% confidence interval {CI} = 3.45-17.10]) while the Brief Alzheimer's Screen most accurately ruled out dementia (LR- = 0.10 [95% CI = 0.02-0.28]). Using estimates of diagnostic accuracy for AMT-4 from this meta-analysis as one trigger for more comprehensive geriatric vulnerability assessments, ED dementia screening benefits patients when the prescreening probability of dementia is between 14 and 36%.

CONCLUSIONS

ED-based diagnostic research for dementia screening is limited to a few studies using an inadequate criterion standard with variable masking of interpreter's access to the index test and the criterion standard. Standardizing the geriatric ED cognitive assessment methods, measures, and nomenclature is necessary to reduce uncertainties about diagnostic accuracy, reliability, and relevance in this acute care setting. The AMT-4 is currently the most accurate ED screening instrument to increase the probability of dementia and the Brief Alzheimer's Screen is the most accurate to decrease the probability of dementia. Dementia screening as one marker of vulnerability to initiate comprehensive geriatric assessment is warranted based on test-treatment threshold calculations.

Quality improvement collaborative aiming for Proactive HEAlthcare of Older People in Care Homes (PEACH): a realist evaluation protocol

INTRODUCTION

This protocol describes a study of a quality improvement collaborative (QIC) to support implementation and delivery of comprehensive geriatric assessment (CGA) in UK care homes. The QIC will be formed of health and social care professionals working in and with care homes and will be supported by clinical, quality improvement and research specialists. QIC participants will receive quality improvement training using the Model for Improvement. An appreciative approach to working with care homes will be encouraged through facilitated shared learning events, quality improvement coaching and assistance with project evaluation.

METHODS AND ANALYSIS

The QIC will be delivered across a range of partnering organisations which plan, deliver and evaluate health services for care home residents in four local areas of one geographical region. A realist evaluation framework will be used to develop a programme theory informing how QICs are thought to work, for whom and in what ways when used to implement and deliver CGA in care homes. Data collection will involve participant observations of the QIC over 18 months, and interviews/focus groups with QIC participants to iteratively define, refine, test or refute the programme theory. Two researchers will analyse field notes, and interview/focus group transcripts, coding data using inductive and deductive analysis. The key findings and linked programme theory will be summarised as context-mechanism-outcome configurations describing what needs to be in place to use QICs to implement service improvements in care homes.

ETHICS AND DISSEMINATION

The study protocol was reviewed by the National Health Service Health Research Authority (London Bromley research ethics committee reference: 205840) and the University of Nottingham (reference: LT07092016) ethics committees. Both determined that the Proactive HEAlthcare of Older People in Care Homes study was a service and quality improvement initiative. Findings will be shared nationally and internationally through conference presentations, publication in peer-reviewed journals, a graphical illustration and a dissemination video.

A qualitative study of the determinants of adherence to NICE falls guideline in managing older fallers attending an emergency department

Background

The National Institute for Health and Care Excellence (NICE) 2004 Falls guideline was developed to improve the assessment and management of falls and prevention of future falls. However, adherence to the guideline can be poor. As emergency departments (EDs) are usually consulted by older adults (aged 65 and over) who experience a fall, they provide a setting in which assessments can be conducted or referrals made to more appropriate settings.

The objective of this study was to investigate how falls are managed in EDs, reasons why guideline recommendations are not always followed, and what happens instead.

Methods

The study involved two EDs. We undertook 27 episodes of observation of healthcare professional interactions with patients aged 65 or over presenting with a fall, supported by review of the clinical records of these interactions, and subsequently, 30 interviews with healthcare professionals. The qualitative analysis used the framework approach.

Results

Various barriers and enablers (i.e. determinants of practice) influenced adherence at both EDs, including the following: support from senior staff; education; cross-boundary care; definition of falls; communication; organisational factors; and staffing.

Conclusions

A variety of factors influence adherence to the Falls guideline within an ED, and it may be difficult to address all of them simultaneously. Simple interventions such as education and pro-formas are unlikely to have substantial effects alone. However, taking advantage of the influence of senior staff on juniors could enhance adherence. In addition, collaborative care with other NHS services offers a potential approach for emergency practitioners to play a part in managing and preventing falls.

How the Availability of Observation Status Affects Emergency Physician Decisionmaking

STUDY OBJECTIVE

This study seeks to understand how emergency physicians decide to use observation services, and how placing a patient under observation influences physicians' subsequent decisionmaking.

METHODS

We conducted detailed semistructured interviews with 24 emergency physicians, including 10 from a hospital in the US Midwest, and 14 from 2 hospitals in central and northern England. Data were extracted from the interview transcripts with open coding and analyzed with axial coding.

RESULTS

We found that physicians used a mix of intuitive and analytic thinking in initial decisions to admit, observe, or discharge patients, depending on the physician's individual level of risk aversion. Placing patients under observation made some physicians more systematic, whereas others cautioned against overreliance on observation services in the face of uncertainty.

CONCLUSION

Emergency physicians routinely make decisions in a highly resource-constrained environment. Observation services can relax these constraints by providing physicians with additional time, but absent clear protocols and metacognitive reflection on physician practice patterns, this may hinder, rather than facilitate, decisionmaking.

High xylan recovery using two stage alkali pre-treatment process from high lignin biomass and its valorisation to xylooligosaccharides of low degree of polymerisation

In the present work, xylan from arecanut husk was extracted using 2 stage alkaline pretreatment process. In first step, biomass was incubated in alkali at different temperatures (25 °C, 50 °C and 65 °C), alkali concentrations (5%, 10%, 15% and 20% w/v), and incubation periods (8 h, 16 h and 24 h) and evaluated for xylan recovery. It was observed that 40-52% of available xylan could be recovered using 10% alkali when incubated for 8-24 h at 65 °C. Subsequently, the alkali pretreatment operating conditions which provided good xylan recovery were processed further using hydrothermal treatment to extract more xylan. For maximum xylan recovery (>90%), best operating conditions were identified when biomass was treated under hydrothermal treatment (1, 1.5 and 2 h) with varying incubation periods (8, 16, 24 h) and alkali concentrations (5%, 10%) using full factorial design. Incubating arecanut husk with 10% w/v NaOH, at 65 °C for a period of 8 h, followed by hydrothermal treatment at 121 °C for 1 h helped recover >94% xylan. In the next step, enzymatic hydrolysis process was optimized to recover maximum XOS (Optimized condition: 50 °C, pH 4 and 10 U enzyme dose). The hydrolysate comprised of xylobiose: 25.0 ± 1.2 g/100 g xylan (∼71% of XOS), xylotriose: 9.2 ± 0.65 g/100 g xylan (26.2% of XOS) and xylotetrose: 0.9 ± 0.04 g/100 g xylan (2% of XOS). The developed process enables to reduce alkali consumption for high recovery of xylan from biomass with relatively higher lignin content for its valorisation into a potential prebiotic oligosaccharide.

Standard set of health outcome measures for older persons

BACKGROUND

The International Consortium for Health Outcomes Measurement (ICHOM) was founded in 2012 to propose consensus-based measurement tools and documentation for different conditions and populations.This article describes how the ICHOM Older Person Working Group followed a consensus-driven modified Delphi technique to develop multiple global outcome measures in older persons. The standard set of outcome measures developed by this group will support the ability of healthcare systems to improve their care pathways and quality of care. An additional benefit will be the opportunity to compare variations in outcomes which encourages and supports learning between different health care systems that drives quality improvement. These outcome measures were not developed for use in research. They are aimed at non researchers in healthcare provision and those who pay for these services.

METHODS

A modified Delphi technique utilising a value based healthcare framework was applied by an international panel to arrive at consensus decisions.To inform the panel meetings, information was sought from literature reviews, longitudinal ageing surveys and a focus group.

RESULTS

The outcome measures developed and recommended were participation in decision making, autonomy and control, mood and emotional health, loneliness and isolation, pain, activities of daily living, frailty, time spent in hospital, overall survival, carer burden, polypharmacy, falls and place of death mapped to a three tier value based healthcare framework.

CONCLUSIONS

The first global health standard set of outcome measures in older persons has been developed to enable health care systems improve the quality of care provided to older persons.

Five-year forward view: lessons from emergency care at the extremes of age

Objective The progressive rise in demand on NHS emergency care resources is partly attributable to increases in attendances of children and older people. A quality gap exists in the care provision for the old and the young. The Five Year Forward View suggested new models of care but that the "answer is not one-size-fits-all". This article discusses the urgent need for person-centred outcome measures to bridge the gap that exists between demand and provision. Design This review is based on evidence gathered from literature searching across several platforms using a variety of search terms to account for the obvious heterogeneity, drawing on key 'think-tank' evidence. Settings Qualitative and quantitative studies examining approaches to caring for individuals at the extremes of age. Participants Individuals at the extremes of age (infants and older people). Main Outcome Measures Understanding similarities and disparities in the care of individuals at the extremes of age in an emergency and non-emergency context. Results There exists several similarities and disparities in the care of individuals at the extremes of age. The increasing burden of health disease on the economy must acknowledge the challenges that exist in managing patients in emergency settings at the extremes of age and build systems to acknowledge the traits these individuals exhibit. Conclusion Commissioners of services must optimise the models of care delivery by appreciating the similarities and differences between care requirements in these two large groups seeking emergency care.

The growing challenge of major trauma in older people: a role for comprehensive geriatric assessment?

In this commentary article, we describe the impact that an ageing population is having on the nature of major trauma seen in emergency departments. The proportion of major trauma victims who are older people is rapidly increasing and a fall from standing is now the most common mechanism of injury in major trauma. Potential barriers to effective care of this patient group are highlighted, including: a lack of consensus regarding triage criteria; potentially misleading physiological parameters within triage criteria; non-linear patient presentations and diagnostic nihilism. We argue that the complex ongoing care and rehabilitation needs of older patients with major trauma may be best met through Comprehensive Geriatric Assessment (CGA). Furthermore, the use of frailty screening tools may facilitate more informed early decision-making in relation to treatment interventions in older trauma victims. We call for geriatric medicine and emergency medicine departments to collaborate-equipping urgent care staff with the basic competencies necessary to initiate CGA should be a priority, and geriatricians have a key role to play in delivery of such educational interventions.

CDK4 in lung, and head and neck cancers in old age: evaluation as a biomarker

BACKGROUND

Cyclin dependent kinases (CDK) are key factors in promoting the initiation and development of tumors. These kinases are important for maintenance of mitochondrial biogenesis and imbalance in their expression in old age may lead to the oxidative stress. Lung cancer (LC), and head and neck squamous cell carcinoma (HNSCC) are two very prominent cancers in older Indians. Both the cancers are showing increasing trend in older population. The present study assessed serum concentration of one of the kinases; CDK4 in older LC and HNSCC patients.

METHODS

The study included 100 subjects each of LC and HNSCC; and older subjects without cancer or any major health problems as controls. Serum CDK4 concentration was estimated using real-time label-free Surface plasmon resonance (SPR) and was verified by western blot.

RESULTS

Significant elevation in serum CDK4 was observed in cases with LC and HNSCC compared to controls. HNSCC patients with higher CDK4 expression had distinctly shorter survival than patients with comparatively lower CDK4 expression. No such difference was observed in LC patients. The germ line mutation study of this gene in Exon-2 was performed and none was observed among cases and controls.

CONCLUSION

It can be concluded that older patients with HNSCC and lung cancer have raised serums CDK4 levels, which has the potential to emerge as a biomarker in clinical practice.

Blood transfusion in preterm infants improves intestinal tissue oxygenation without alteration in blood flow

BACKGROUND AND OBJECTIVE

The objective of the study was to investigate the splanchnic blood flow velocity and oximetry response to blood transfusion in preterm infants according to postnatal age.

MATERIALS AND METHODS

Preterm infants receiving blood transfusion were recruited to three groups: 1-7 (group 1; n = 20), 8-28 (group 2; n = 21) and ≥29 days of life (group 3; n = 18). Superior mesenteric artery (SMA) peak systolic (PSV) and diastolic velocities were measured 30-60 min pre- and post-transfusion using Doppler ultrasound scan. Splanchnic tissue haemoglobin index (sTHI), tissue oxygenation index (sTOI) and fractional tissue oxygen extraction (sFTOE) were measured from 15-20 min before to post-transfusion using near-infrared spectroscopy.

RESULTS

The mean pretransfusion Hb in group 1, 2 and 3 was 11, 10 and 9 g/dl, respectively. The mean (SD) pretransfusion SMA PSV in group 1, 2 and 3 was 0·63 (0·32), 0·81 (0·33) and 0·97 (0·40) m/s, respectively, and this did not change significantly following transfusion. The mean (SD) pretransfusion sTOI in group 1, 2 and 3 was 36·7 (19·3), 44·6 (10·4) and 41·3 (10·4)%, respectively. The sTHI and sTOI increased (P < 0·01), and sFTOE decreased (P < 0·01) following transfusion in all groups. On multivariate analysis, changes in SMA PSV and sTOI following blood transfusion were not associated with PDA, feeding, pretransfusion Hb and mean blood pressure.

CONCLUSION

Pretransfusion baseline splanchnic tissue oximetry and blood flow velocity varied with postnatal age. Blood transfusion improved intestinal tissue oxygenation without altering mesenteric blood flow velocity irrespective of postnatal ages.

Molecular signature of extended spectrum β-lactamase producing Klebsiella pneumoniae isolated from bovine milk in eastern and north-eastern India

The present study reports on 23 extended spectrum β-lactamase producing Klebsiella pneumoniae (KP), isolated from milk samples (n=340) of healthy cows (n=129) and cows with subclinical (n=159) and clinical (n=52) mastitis, from three different states of India viz. West Bengal, Jharkhand and Mizoram. Seven of them were AmpC type β-lactamase producers, as well. The ESBL producing KP were significantly (P=0.006, χ2=10.04, df=2) and more frequently detected in milk samples of mastitic cows than healthy ones. The β-lactamase genes - blaCTX-M, blaTEM and blaSHV were detected in 19, 8 and 3 isolates, respectively. In all but one CTX-M positive isolates, the genetic platform - ISEcp1-blaCTX-M-orf477 was detected. Ten of the isolates carried plasmid mediated quinolone resistance gene - qnrS and 1 isolate possessed qnrB. Again 11 of them were found to have sulfonamide resistance gene - sul1 and 12 possessed class I integron. Sequencing of the class 1 integron revealed the presence of dfrA12/dfrA17 and aadA2/aadA5 gene cassettes conferring resistance to trimethoprim and aminoglycosides, respectively. All the isolates, characterized by enterobacterial repetitive intergenic consensus (ERIC) PCR, yielded distinct fingerprinting profile. However, most of the isolates from Jharkhand were clustered along with two isolates each from West Bengal and Mizoram indicating their clonal relatedness even though isolated from geographically different areas. Isolation of ESBL producing KP from bovine milk samples implies its public health significance; as such pathogens may enter the human food chain causing severe health hazards.

Cerebral blood flow and oximetry response to blood transfusion in relation to chronological age in preterm infants

OBJECTIVE

Preterm infants frequently receive blood transfusion (BT) and the aim of this study was to measure the effect of BT on cerebral blood flow and oxygenation in preterm infants in relation to chronological age.

PATIENTS

Preterm infants undergoing intensive care recruited to three chronological age groups: 1 to 7 (Group 1; n=20), 8 to 28 (Group 2; n=21) & ≥29days of life (Group 3; n=18).

METHODS

Pre and post-BT anterior cerebral artery (ACA) time averaged mean velocity (TAMV) and superior vena cava (SVC) flow were measured. Cerebral Tissue Haemoglobin Index (cTHI) and Oxygenation Index (cTOI) were measured from 15-20min before to 15-20min post-BT using NIRS. Vital parameters and blood pressure were measured continuously.

RESULTS

Mean BP increased significantly, and there was no significant change in vital parameters following BT. Pre-BT ACA TAMV was higher in Group 2 and 3 compared to Group 1 (p<0.001). Pre-BT ACA TAMV decreased significantly (p≤0.04) in all 3 groups; pre-BT SVC flow decreased significantly in Group 1 (p=0.03) and Group 3 (p<0.001) following BT. Pre-BT cTOI was significantly lower in Group 3 compared to Group 1 (p=0.02). cTHI (p<0.001) and cTOI (p<0.05) increased significantly post-BT in all three groups. PDA had no effect on these measurements.

CONCLUSION

Baseline cTOI decreases and ACA TAMV increases with increasing chronological age. Blood transfusion increased cTOI and cTHI and decreased ACA TAMV in all groups. PDA had no impact on the baseline cerebral oximetry and blood flow as well as changes following blood transfusion.