Introduction NICE guidelines state that fracture risk assessment should occur in all women aged ≥65 and all men aged ≥75. This includes assessing patients’ FRAX score, measuring serum vitamin D and calcium levels. Early detection and treatment can prevent complications like fragility fractures. We conducted a Quality Improvement Project to improve bone health assessments on Geriatric Wards. Methods A baseline audit assessed: admission reason, falls history, FRAX score, CFS, previous DEXA scans, whether vitamin D and calcium levels were checked during the admission, and if treatment was commenced (bone resorption medication and vitamin D/calcium supplements). Data was collected two further times following interventions over a 5-month period. The first intervention was an announcement at the morning departmental meeting reminding clinicians. The second intervention was an email reminder. Results There were 56, 51, and 58 patients per cycle. 19, 15, and 17 patients were admitted with falls. 23, 14, and 10 patients had a falls history. Average CFS was 5.4, 5.4, and 5.5. Average major osteoporotic fracture FRAX score was 15.8, 16.4, and 12.9. Checking serum calcium was 88%, 100%, and 100%. Checking vitamin D was 30%, 43%, and 60%. 28%, 43%, and 47% of patients were prescribed calcium and vitamin D supplements. Patients on bone resorptive treatment dropped from 7% to 3% to 2%. 8, 12, and 11 patients had a previous DEXA. Discussion Verbal announcement had the greatest impact. Visible reminders help sustainability. This QIP highlighted the lack of bone protection treatment with multiple contributing factors including some patients lacking the capacity to follow instructions to take weekly medications or patients requiring vitamin D being replaced initially, with initiation later. This QIP feeds into a larger trust project in developing a ‘Fracture Liaison Service’, which could improve adherence and provide a pathway in utilising annual and bi-annual treatments.

Introduction About 300,000 people living with Frailty undergo operations annually. Current evidence suggests that comprehensive geriatric assessment (CGA) pre-operatively enhances shared decision making (SDM), equity of access to surgery, length of stay (LOS) and mortality. Multiple NCEPOD reports, the National Emergency Laparotomy Audit (NELA) and National Hip Fracture Database (NHFD) programs have highlighted the unmet need in caring for these patients. Our aim was to introduce a novel combined Geriatrician/Anaesthetist pre-assessment clinic to provide better SDM and perioperative optimisation to improve outcomes for elective colorectal surgery. Method We performed combined CGA and Anaesthetic pre-operative assessment in patients undergoing elective colorectal surgery aged ≥65 years between July 2021 to August 2022. Data including Clinical Frailty Score (CFS), LOS, Type of surgery, P-POSSUM Score, 30-day mortality and 90-Day mortality were analysed. Results We reviewed 48 patients in 14 months. 69% patients underwent surgery and 27% declined after a comprehensive SDM process. The median age of operated patients was 80 (65-94) compared with 74 in 2020-21. 58% of patients operated were over 80, compared to 24% in 2020-21, prior to clinic inception. The median CFS was 4. 55% of patients had a LOS ≤7days (73% in 2020-21), 32% was 8-14days (18%) and 13% was >14days in hospital (9%) respectively. 32% had a P-POSSUM score of ≥5% whereas 10% had a score of >15%. The overall 30-day and 90-day mortality rates for our cohort was 0%, compared with 0% and 3% respectively in 2020-21. Conclusion Our data suggests that our clinic has enhanced equity of access to curative colorectal cancer surgery for older adults. 90 days mortality remained 0% owing to excellent patient selection and enhanced perioperative care. Importantly, 27% of patients declined surgery after an extensive process of SDM. Further work needs to be completed assessing decision regret and satisfaction with SDM (SDMQ9).

Introduction Acquired Hemophilia is a bleeding diathesis caused by autoantibodies that interfere with factor VIII (FVIII). Reasons for autoantibodies production are not clear but may be related to gene polymorphisms and/or CD4+ T lymphocytes. 1.3 to 1.5 cases per million population per year are reported in the UK. Half of the cases are secondary to malignancy, pregnancy related conditions, connective tissue disorders or drug reactions while the rest are idiopathic. Case Report We report a case of an acquired hemophilia A in an 86-year-old lady with underlying type 2 diabetes, hypertension, and cognitive impairment, being treated as the left lower limb cellulitis with antibiotics. She was found to have a sudden hemoglobin drop and her CT (Abdomen) confirmed a spontaneous intra-abdominal hematoma. Clotting profile showed prolonged APTT to 168.5 seconds, being not corrected at mixing study, with normal PT and INR. The FVIII assay was reduced to 18.4 iU/dL with FVIII inhibitor concentration of 0.7 Bu. Viral and autoimmune screenings were negative. The idiopathic acquired hemophilia A was diagnosed. Red blood cell transfusions, bypassing agents (FEIBA) and oral tranexamic acid were given for acute bleeding episode. Concomitantly, oral prednisolone was used to reduce the inhibitor levels. Repeated FVIII assay showed 121 iU/dL and 199iU/dL on day 6 and 12, respectively. Steroid was continued for the next 4 weeks and then gradually tapered. No further bleeding episode was noted. Conclusion The diagnosis of acquired hemophilia should be considered in any elderly patient with prolonged APTT. Mixing study is to measure the presence of inhibitors of coagulation or to detect coagulation factor deficiency. Quantitative coagulation factor assays and Bethesda Assays are performed for definitive diagnosis. Immunosuppressive regimens are the mainstay treatment. However, premorbid conditions and co-morbidities should be taken into consideration before initiating the aggressive immunosuppressive therapy in the elderly patients.