Aims and objectives:To explore nurse and nursing assistant reflections on the care of older patients with cognitive impairment who have experienced a fall.Background: While there are evidence-based clinical guidelines for the prevention and management of falls and for the care of older people with cognitive impairment, the falls rates for older people with cognitive impairment are three times as high as those without. Design: Critical incident technique.Methods: Eleven registered and two enrolled nurses and four assistants in nursing working in one subacute and two acute wards within two hospitals of a tertiary level health service in south-east Queensland. Individual semistructured interviews focused on two past events when a patient with cognitive impairment had fallen in hospital: one when there was minimal harm and the second when there was significant harm. Thematic analysis was undertaken. The COREQ checklist was followed.Results: Three themes emerged from 23 reflective accounts of fall events: "direct observation is confounded by multiple observers" and "knowing the person has cognitive impairment is not enough," and "want to rely on the guideline but unsure how to enact it." While participants were aware of the falls prevention policy and techniques available to prevent falls, the implementation of these was challenging due to the complexity of care required by the older person with cognitive impairment. Conclusions:Falls prevention for older people with cognitive impairment is complex and belies the simple application of policy. Relevance to clinical practice:To reduce falls, nurses can involve the family to support "knowing the patient" to enable prediction of impulsive actions; shift the focus of in-service from lectures to specific case presentations, with collaborative analysis on personfocused strategies to prevent falls in older people with cognitive impairment; and reconsider the sitter role from simple observer to assistant, focused on ambulation and supporting independence in activities of daily living. K E Y W O R D Sdementia, falls, hospitalised patients, older patients, patient safety | 1347 GREALISH Et AL.

Background: Evidence-based guidelines assist clinicians in practice, but how the guidelines are implemented is less established.Aim: To describe the nurses' implementation of activities recommended in evidence-based guidelines for falls prevention and care of older people with cognitive impairment.Methods: Structured observation with a categorical checklist was used. Nursing personnel were recruited from one subacute and two acute wards in two hospitals in one tertiary-level health service in south-eastern Queensland, Australia. The data collection instrument identified 31 activities drawn directly from the evidence-based guidelines, which were categorized into six domains of nursing practice: clinical care, comfort, elimination, mobility, nutrition and hydration, and social engagement. Four-hour observation periods, timed to occur across the morning and evening shifts, were conducted over 2 months.Results: Nineteen registered nurses, six enrolled nurses, and 16 assistants in nursing (N = 41) were observed for 155 hr of observation. There was variability in adherence with specific activities, ranging from 21% to 100% adherence. Three categories with the highest adherence were nutrition and hydration, mobilization safety, and social engagement. The clinical care, comfort, and elimination categories had lower adherence, with lowest adherence in activities of education provision about falls risk, pain assessment, using a clock or calendar to reorient to time and place, and bowel care.Linking Evidence to Action: Nursing care is delivered within an interdisciplinary team. Therefore, responsibility for the everyday fundamental care activities known to prevent falls in older people with cognitive impairment requires localized negotiation. A practical guide for preventing in-hospital falls in older people with cognitive impairment addressing the interdisciplinary context of practice is required. Interdisciplinary teams should develop strategies to enhance the implementation of pain assessment and prevention of constipation in the context of regularly implemented hydration, nutrition, and mobilization care strategies.

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Background Stage I/II or early-stage follicular lymphoma (ESFL) is considered potentially curable with radiotherapy (XRT). While XRT does achieve local disease control in >90% of cases, more than half the patients (pts) relapse by 10 years (yr), generally outside of the radiation field. A recent randomized controlled trial (TROG 99.03) demonstrated that combined modality therapy (CMT), with sequential XRT and systemic therapy, significantly improved PFS but not overall survival (OS) compared to XRT alone in ESFL. However, only half the pts were staged with 18F‐FDG positron emission tomography and computed tomography (PET) and 58% of CMT pts did not receive rituximab.Compared with CT staging, 20-60% of cases are upstaged by PET. Consequentially, there are limitations in applying this trial to modern populations. Despite the support of current guidelines, only one third of pts in clinical practice are treated with XRT. This suggests a need to better understand the role of other treatments, including watchful waiting (WW), in the PETera. Our aim was to compare outcomes with real-world treatment approaches in rigorously staged ESFL patients. Methods We conducted an international, multicenterretrospective study of stage I and II FL pts rigorously staged with bone marrow biopsy and PET. Eligible pts were >18yr with newly-diagnosed grade 1-3A FL and ≥3 months follow up. Primary outcome measures were overall response rate (ORR), progression free survival (PFS), OS and risk of transformation. Survival curves were estimated with the Kaplan-Meier method and uni- and multi-variate analysis was performed using Cox regression model. Results A total of 387 pts treated at 13 Australian and 3 Canadian centres between 2005-2017 were studied. Median follow-up was 45 months (range 3.1 - 164.0).5-yrPFS and OS rates were 73.5% (95% CI 66.0-78.5) and 94.4% (95% CI 89.4-93.6) respectively. 22 patients had stage IE duodenal FL with 5-yr PFS and OS rates of 100% and 100% respectively. Considering the unique biology and favorable prognosis of duodenal FL, these cases were excluded from subsequent analyses. Treatment approaches 365 pts included WW (defined as absence of treatment within 6 months from diagnosis) (23.2%), XRT (46.8%), immunochemotherapy (17.2%) and CMT (12.6%). Treatment regimens were: R-CHOP (48.1%), R-CVP (24.4%), BR (9.9%), other (17.6%). First-line therapies for actively treated pts yielded comparable ORRs of 95.6%, 96.7% and 95.9% for XRT, immunochemotherapy and CMT, respectively (P=0.94). Overall, 18.2% of pts relapsed at distant sites, 88.2% of all relapses. Treatment cohorts differed in baseline clinical characteristics. WW pts were significantly older (P=0.007) but otherwise comparable to those treated actively. Compared to chemotherapy or CMT pts, those treated with XRT had more favorable features including fewer B symptoms (4.2% vs 11.2% p=0.029), bulk (≥7cm) (6.8% vs 25.3%, p<0.001), nodal sites (≥3) (1.9% vs 9.5% p=0.005) and a higher frequency of stage I FL (73.1% vs 42.1% p<0.001). Outcomes differed among treatment approaches. Active treatment was associated with superior PFS compared with WW pts (HR 0.54 p=0.004) however, 49.4% of WW pts remained untreated at 5-yrs (Fig 1a). Considering actively treated pts, systemic therapy (immunochemotherapy or CMT) was associated with superior PFS compared to XRT by univariate analysis (HR 0.49, p=0.009) (Fig 1b). This association remained after multivariate adjustment for bulk, B symptoms, nodal sites and stage (HR 0.41 p=0.002). Treatment with immunochemotherapy and CMT demonstrated a comparable PFS (p=0.2). Maintenance rituximab (n=45) was associated with superior PFS compared with observation after systemic therapy (HR 0.24, p=0.017). There were no differences in OS among treatment approaches (P=0.734). There was a higher incidence of transformation in XRT pts compared to systemic therapy pts (6.4% vs 1.6% p=0.046). Conclusion In the largest assessment of rigorously-staged ESFL pts in the PETera, pts treated with systemic therapy (chemotherapy or CMT) had a superior PFS and a lower rate of transformation compared to pts treated with XRT, although treatments were not randomized. These findings are similar to the TROG 99.03 trial and challenge the paradigm that ESFL should be uniformly treated with XRT alone. Half the pts observed from diagnosis remained treatment-free at 5-yrs, suggesting that WW may be appropriate in selected pts. Disclosures Tobin: Celgene: Research Funding; Amgen: Other: Educational Travel. Tam:Roche: Honoraria; Roche: Honoraria; Pharmacyclics: Honoraria, Travel funding; Pharmacyclics: Honoraria; Beigene: Honoraria, Other: Travel funding; Beigene: Honoraria, Other: Travel funding; AbbVie: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Gilead: Honoraria; Gilead: Honoraria; AbbVie: Honoraria, Research Funding. Abro:Amgen: Other: education support congress attendance; Celgene: Other: education support congress attendance; Bristol-Myers Squibb: Speakers Bureau; Janssen: Other: education support congress attendance; Novartis: Consultancy. Hawkes:Bristol Myers Squibb: Other: Speaker fee, Research Funding; Takeda: Other: Speaker fee; Astra Zeneca: Research Funding; Merck Sharpe Dohme: Research Funding; Merck KGA: Research Funding; Celgene: Other: Advisory board, Research Funding; Merck: Other: Advisory board; Roche: Other: Speaker fee; advisory board. Talaulikar:Amgen: Consultancy, Honoraria; Roche: Honoraria, Speakers Bureau; Janssen: Honoraria, Speakers Bureau; Takeda: Research Funding; Novartis: Honoraria, Speakers Bureau. Gandhi:Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Merck: Honoraria, Membership on an entity's Board of Directors or advisory committees; Amgen: Honoraria; Takeda: Honoraria; Gilead: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; BMS: Membership on an entity's Board of Directors or advisory committees, Research Funding.