Deconditioning and rehabilitation

Background  

University Hospital Southampton (UHS) partnered with Saints Foundation (SF), to test the feasibility and acceptability of a non-registered Exercise Practitioner (EP) to work alongside the therapy team to promote physical activity (PA) of hospitalised older people. Our aim was to collect trust level data to review the impact the EP had on outcomes such as length of stay (LOS) and discharge destination (DD) and identify and address any additional challenges that arose. 

Methods  

The EP delivered twice weekly gym-based group interventions as well as regular 1:1 rehabilitation and education sessions to hospitalised older patients. Interventions were ward based or within the acute therapy gym.  

Results  

Between June and August 2023 the EP reviewed 82 patients, mean age of 88 years. 15 (18%) patients underwent 1:1 rehabilitation whereas 67 (82%) patients underwent gym-based rehabilitation sessions. Median LOS for patients reviewed by the EP was 15 days compared with average departmental LOS of 8 days. 53 (65%) patients were able to either maintain or improve their predicted to actual discharge destination, compared with 10 (12%) patients whose physical capability declined. Of those remaining, 1 patient died and 18 others had not yet been discharged. High patient satisfaction levels continued to be reported.  

Conclusion  

Intervention by a non-registered EP appears to have an impact on patients’ ability to maintain or improve level of function and physical dependency during acute hospital stay.  Factors such as outbreaks of infectious illness and staffing challenges prevented more frequent EP led intervention. Next steps include introducing daily class-based interventions. Participants will be encouraged to attend at least three classes. Anticipated benefits include improvement in patients’ functional levels and reductions in physical dependency on discharge.  Additional data will be collected on fear of falling and confidence in function as well as uptake of post discharge activity and readmission. 

Introduction

Hospital-acquired deconditioning (HAD) leads to functional decline, extended hospital stays, increased fall risk, and higher readmission rates, resulting in a significant cost burden on the NHS. Preventing HAD through early and regular physical rehabilitation is crucial for improving patient outcomes and reducing healthcare costs. This Quality improvement project , conducted in a ward, aimed to evaluate and enhance the implementation and effectiveness of physical rehabilitation programs to prevent HAD.

Method

The project began with administering questionnaires to both staff and patients to assess their knowledge about HAD, its significance, and the importance of physical rehabilitation. Following the initial data collection, educational leaflets and teaching sessions were provided to both groups to raise awareness and improve understanding. Post-intervention data were collected using the same questionnaires to evaluate changes in awareness and practices.

Results

The post-intervention data showed significant improvements. Staff awareness of deconditioning risks increased (3.8x post-intervention vs. 1.4x pre-intervention), and the time spent mobilizing patients increased (4.7 hours per shift vs. 3.5 hours per shift). Patients showed a better understanding of the importance of sitting out (9.0 to 9.6/10) and engaging with physiotherapy (5.6 to 9.7/10), along with heightened awareness of the dangers of bed rest (8.5 to 9.5/10). These outcomes indicate that the intervention effectively enhanced both staff and patient awareness and practices regarding physical rehabilitation.

Conclusion

This intervention significantly improved staff and patient awareness, mobilization efforts, and understanding of rehabilitation's importance, effectively reducing the risk of HAD in the ward. Sustaining these improvements requires ongoing staff training, regular audits, and continuous education for both patients and healthcare providers. By preventing HAD, these efforts enhance patient outcomes and reduce the NHS's financial burden due to readmissions and prolonged hospital stays. The study highlights the crucial role of education and structured rehabilitation programs in combating hospital-acquired deconditioning.

Introduction: Hospital-Associated Deconditioning Syndrome (HADS) can lead to prolonged length of stay (LOS). Evidence indicates that early intervention may reduce HADS and LOS. (British Geriatrics Society, Deconditioning, Healthy Ageing, 11 May 2017, Dr Amit Arora, NHS England, 24 January 2017, Time to Move). The Acute Frailty Team (AFT) at Eastbourne District General Hospital piloted a Frailty Early Discharge Scheme (FEDS) in the Frailty Unit for 8 weeks between May-June 2023 with the aim of providing early mobilisation and discharge planning to reduce LOS.

Methods: Patients were admitted to either FEDS or Non-FEDS (NFEDS) beds depending on the bed availability. FEDS patients were provided with additional early assessments and interventions including discharge plans from day 1 after admission, offering early, continuous and active mobilisation by a trained FEDS team of a registered Nurse and Health Care Assistant. The FEDS team worked in conjunction with the medical team to actively promote discharge planning while patients were still receiving acute medical treatment, before patients becoming medically fit for discharge (MFFD). NFEDS followed the standard care plan, usually initiated after patients were declared MFFD. Data was collected for all patients, comparing FEDS 12 beds with NFEDS 12 beds.

Results: 83 patients were enrolled 45 FEDS, 38 NFEDS Discharged within 48hrs FEDS 11.11%, NFEDS 2.63% Discharged within 7 days FEDS 44.44%, NFEDS 28.94% LOS 8.07 days FEDS, 11.36 days NFEDS (30 day trim point).

Conclusions: 1. Increased rate of discharge within 48 hrs and 7 days. 2. Reduced LOS within 30 days. 3. The benefit is mostly noticed within the first 7 days indicating the need to apply the intervention early 4. The adoption of a FEDS-project in all frailty wards could be beneficial for elderly patients.

Introduction:

As awareness of hospital-associated deconditioning increases, services to prevent hospital admissions and provide discharge support for older adults are expanding, aiming to reduce admissions and the risks associated with prolonged hospital stays. A Welsh Government IQS titled “Older People and People Living with Frailty” published in January 2024 identifies a need to shift our health and social care system from prioritising reactive crisis management to a ‘place-based’, community-focused approach that emphasises proactive identification and management of frailty. The CTMUHB @Home Service (AHS) was instituted in 2017 to provide domiciliary and community-based care to patients at risk of hospital admission, covering Rhondda, Cynon, Taff Ely and Merthyr Tydfil.

Methods:

A retrospective review of patients discharged from the AHS between February and May 2024 was completed (n=345). Reasons for referral, diagnostic journey details, and patient outcomes were recorded. Alongside this, the IV Antibiotics Service register for the same period was analysed (n=48) to calculate the number of Bed Days saved and its associated cost effectiveness.

Results:

57% of referrals are related to patients’ risk of or recent falls, followed by 16% of patients with increased frailty who are approaching crisis. 8% of patients have been referred for the specialised services of the AHS, such as COPD reviews, discharge support, pharmacological optimisation, or follow-up blood tests. Most referrals originate from GPs, with other sources including facilitated discharges or WAST. Bed day costs saved from the IV Antibiotics Service are estimated to be £358,000.

Conclusion:

We now have a better understanding of the AHS’ monthly patient in and outflow. Although the substantial cost savings seem positive, it is still uncertain whether this conclusively measures the AHS’ cost-effectiveness. This understanding will help pave the next steps towards increasing awareness about the functions of the AHS as a hospital avoidance team focused on frailty.

Introduction: Sedentary behaviour has been associated with several deleterious health outcomes and older adults are the fastest-growing and most sedentary group in society. This review aimed to systematically review quantitative and qualitative studies examining interventions to reduce sedentary behaviour in community-dwelling older adults.

Methods: This mixed-method systematic review (PROSPERO registration number: CRD42021264954) considered quantitative articles (randomised-controlled trials (RCTs) and cluster RCTs), qualitative articles (semi-structured interviews and focus groups) and mixed-method studies that explored interventions to reduce sedentary behaviour in community-dwelling older adults. Medline, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Cinahl, SportDiscus and PEDRO were searched from inception to March 2023. Articles were appraised using the Mixed Method Appraisal Tool. Quantitative evidence was meta-analysed, qualitative evidence was thematically synthesised and both were combined in a mixed-method synthesis.

Results: Forty-one studies (15 RCTs, 21 qualitative and 5 mixed-method studies) were included. Interventions were somewhat effective at reducing sedentary time (-29.10 mins/day, 95% CI -51.74, -6.46). Three analytical themes were identified (what sitting means to older adults, expectations of ageing and social influence in older adults). The mixed-method synthesis identified that existing interventions have been limited by a recruited sample that is not representative of the wider population of older adults, and outcome measurement and intervention content that is not consistent with older adults’ priorities.

Conclusions: Future research should focus on inclusive recruitment strategies to recruit underrepresented populations (such as adults aged 75 years and above), incorporate outcome measures that are valued by older adults, and incorporate older adults’ preferences in intervention content.

Introduction. Concerns about falling are common among older adults. Many older adults with concerns about falling will restrict their activities. This can trigger a vicious cycle of physical deconditioning, falls, social isolation, reduced confidence, and a loss of one’s sense of self. However, not every older adult with concerns about falling will restrict their activities. In this prospective cohort study we therefore investigated the factors that predict the development of activity restriction due to concerns about falling in older people aged ≥75 years.

Methods. Data were collected as part of the Community Ageing Research 75+ (CARE75+) study. For the baseline (T1) timepoint, we extracted data for 543 older adults who did not report activity restriction due to concerns about falling completed a set of physical and psycho-social assessments. We then assessed which baseline variables predicted the onset of activity restriction at T2 (12-months later).

Results. Of the total sample, 55 older adults reported to have started to restrict activity due to concerns about falling at T2 (10.1% of overall sample), while 488 people reported to (still) not restrict their activities (89.9%). Three key predictors significantly predicted activity restriction status at 12-months follow-up: greater frailty (Fried Frailty Index; OR=1.58, 95%CI: 1.09-2.30), faller status (experiencing a fall between T1 and T2; OR=2.22, 95% CI: 1.13-4.38) and poorer functional mobility/balance (Timed up and Go; OR=1.08, 95%CI: 1.01-1.15).

Conclusions. These findings show that frailty, experiencing a fall and poorer functional mobility/balance may result in the development of activity restriction due to concerns about falling. Clinicians working in balance and falls-prevention services should regularly screen for frailty, and patients referred to frailty services should likewise receive tailored treatment to help prevent the development of such activity restriction.

INTRODUCTION: In order to improve resident safety and reduce hospital admissions, the ‘Optimizing Bed Height Quality Improvement Study’ aims to raise awareness among healthcare professionals about the importance of ensuring optimal bed height to prevent falls and injuries in residents and to improve bed mobility.

The parameters from a 2015 study, ‘Analysis of the Influence of Hospital Bed Height on Kinematic Parameters Associated with Patient Falls During Egress', are taken into account when using intervention techniques.

METHODS: Residents aged 65 or over falling out of bed between January and June of 2022 were used as a pre-test measure. By maintaining a hip or knee angle just above 90 degrees, keeping the resident's feet flat on the floor, and ensuring that they can easily transition from sitting to standing and vice versa, the nurse and physiotherapist assessed the resident's mobility and determined the height of the resident's bed. An illustration of the ideal height is displayed on a poster that hangs on the wall above the headboard of the bed. Nurses visit each resident's room each day to ensure that the beds were in the ideal position and record this information in the monitoring system. The data obtained during the six-month period of intervention (July to December 2022) was compared with the pre-test results.

RESULTS: Results from a six-month intervention period (July to December 2022) were compared to those from a six-month pre-intervention phase (January to June 2022) with fourteen bed falls, there was a FIFTY PERCENT decrease in bed falls.

CONCLUSION: After a six-month clinical trial, the study revealed that older adults who had bed falls and trouble getting out of their beds had lower fall rates, suggesting that stakeholders' knowledge of the ideal bed height had increased.

Introduction

The Scottish Care of Older People (SCoOP) collaborative regularly reports outcomes of acute geriatric medicine admissions across Scottish hospitals. The covid pandemic caused major and highly variable restructuring of acute services across the country. Their impact on activity and outcomes is unknown.

Methods

We collated all SMR01/SMR01E hospital episodes from Public Health Scotland from 1^st April 2017 to 31^st March 2022 where over 50% of the total episode was spent under acute geriatric medicine (code AB) and the diagnosis was not stroke. Activity and outcomes in 19 major hospitals were compared across financial years 2017-19 (before-), 2020/21 (during-) and 2021/22 (after lockdowns). 

Results

Admissions fell 15% to 36954 in 2020/21 from an average 42566 before recovering to 41971 in 2021/22. Age, sex and social deprivation profiles differed between hospitals (p<0.001) but remained similar within each hospital at all timepoints. Few hospitals were busier than ever in 2020/21 but some saw large reductions in activity. Mortality at 30 days post-admission was 10% higher in 2020/21 (17.9% v 16.5% in other years, p<0.001), with 2-fold differences across hospitals. Mean median length of stay (LOS) across hospitals was 11.7 days, compared to 12.8 days in 2017-20, p<0.001. There were up to 17-fold differences in median LOS between hospitals (2-34 days) in 2020/21, p<0.001. The impact of the pandemic on LOS within each hospital was also highly variable. Readmission rates at 7 days post-discharge were broadly similar across all years but two-fold differences between hospitals were also seen (4.8%-9.8%, mean 6.8%, p<0.001).

Conclusion

The year 2020/21 saw a 15% fall in acute geriatric medicine admissions overall, with 10% increase in mortality and shorter lengths of stay. However, the impact on the activity and outcomes of individual hospitals were widely disparate, probably reflecting variation in how each hospital service responded to the pandemic.   

Introduction

Frailty is defined as “a condition characterised by loss of biological reserves, failure of physiological mechanisms and consequent increased risk of experiencing a range of adverse outcomes, including hospitalisation, longer length of inpatient stay, and delirium” [1-4]. We aim to investigate the association between baseline frailty and functional recovery amongst hospitalized older adults and its association with inpatient delirium.

Method

Retrospective analysis of patients admitted to a Geriatrics ward from August to November 2022. Interactions between clinical outcomes with age, length of stay (LOS), discharge destination, Charlson Co-morbidity index (CCI) and Clinical Frailty Score (CFS) were evaluated plus incidence of inpatient delirium.

Results

In total, 58 patients reviewed, mean age 78.8 (±15.1) years, 43 (74%) woman. 79% were admitted from their own home with 56% same discharge destination and 9% inpatient mortality. Median LOS in hospital was 13 days with 8 days on the Geriatrics ward. Mean CFS on admission compared to discharge was (4.9 vs 5.7 (p<0.001)), with no significant difference in CCI. There was a significant association between CFS and LOS, both overall and on the Geriatrics ward (P<0.001). 17 patients (29%) developed delirium, with increased LOS (45 days vs 9 (P<0.001)), increased CFS both on admission (5.9 vs 4.4 (p=0.002)) and discharge (7.4 vs 5.0 (p<0.001)) and were less likely to be discharged to their own home (33.3% vs 84.8% (p<0.001)).

Conclusion

Frailty is a powerful predictor for possible risk of deconditioning and is associated with longer acute hospital stay in our more vulnerable patients. The coexistence of frailty and delirium significantly increased the risk of a prolonged hospital stay. This indicates that a multidisciplinary approach to provide a comprehensive geriatric assessment, is necessary to decrease LOSand the incidence of adverse outcomes as during this time period we had limited specialist therapy staff on the ward

Introduction

Covid has had a devastating effect on the Elderly, resulting in deconditioning, increased falls and loneliness. Tailored exercises can reduce falls in people aged over 65 by 54% and participation in physical activity reduces the risk of hip fractures by 50%, currently costing the NHS £1.7 billion per year in England. This 8 week intervention delivered by trained volunteers in patient’s homes, aims to reduce deconditioning, loneliness and the risk, incidence and fear of falling (FOF) amongst frail patients post-discharge from hospital.

Method

A gap in service was identified in Frail patients discharged from hospital, at risk of falling and awaiting community physiotherapy. A steering group was set up including acute and community therapists, volunteers and carers to design a collaborative intervention to bridge the gap. At risk patients were identified and referred by ward therapists supported by the hospital volunteering team. Volunteers were trained to deliver an 8 weeks programme of progressive exercises in patients’ homes with additional signposting to appropriate statutory and voluntary services. Qualitative and quantitative outcome measures were taken at week 1 and week 8 of the intervention

Results

• 91.5% total health outcomes improved or maintained by average
• FOF reduced by 22.5%
• 180 degree turn improved by 43%
• 60 sec Sit to Stand improved by 14.75%
• Timed Up And Go improved by 15.5%
• Confidence to cope at home improved by 15% 
• Pain / discomfort (self-reported) improved by 18.75% 
• Overall health (self-reported) improved by 8.5%

Conclusion(s).

Targeted exercise at home with skilled volunteers can improve functional fitness and health outcomes in a frail elderly population at risk of falls when discharged home from hospital. The programme increases patients’ connectivity to local voluntary and community sector services. Volunteers’ mental health improves by engaging in meaningful service.