Rehabilitation

Introduction

Lakeside unit at the University Hospital of Wales is a rehabilitation and complex discharge planning facility for elderly patients. Recognising the importance of good sleep in rehabilitation, our quality improvement project aimed to assess the feasibility and evaluate the impact of introducing decaffeinated coffee and tea as alternatives to the standard caffeinated options routinely provided to patients. Caffeine is a diuretic and stimulant that disrupts sleep and increases urinary frequency, urgency, and volume. Reducing caffeine can reduce falls related to toileting. Addressing nocturia should be considered in the design of comprehensive fall prevention programs for older adults.

METHODOLOGY

We educated staff and patients about the benefits of decaffeinated drinks through informational sessions and ensured a variety of decaffeinated beverages were available to patients after 5 PM. Over two weeks, our study implemented a controlled intervention, with Week 1 as the baseline control phase. During this period, we assessed falls, frequency of nocturnal toilet visits, and sleep quality. In Week 2, we introduced decaffeinated coffee and tea after 5 PM and continued to monitor the same metrics. Most patients chose decaffeinated drinks when offered.

RESULTS

Data from 202 patient nights in the control week and 240 patient nights in the intervention week were reviewed.

- Sleep:

  - Control: 78% good(157), 22% bad(45)

  - Intervention: 85% good(203), 15% bad(37)

- Falls:

  - Control: 1 fall(0.083 per night per patient)

  - Intervention: 2 falls(0.133 per night per patient)

- Toileting:

  - Control: 0.87 trips per patient per night

  - Intervention: 1.27 trips per patient per night

CONCLUSION

Our small feasibility study noted some improvement in sleep quality, with no significant difference in toileting needs and falls per patient per night. The acceptability of decaffeinated drinks was high. Larger and longer studies are needed to further examine the effects of decaffeinated drinks

Introduction

National guidance suggests that all patients with neck of femur fractures (NOFF) should be mobilised day one post-operatively (NICE, 2023, QS16). This reduces rates of delirium, pneumonia and length of stay (Sallehuddin & Ong, Age and Ageing, 2021, 50, 356-357). Hypotension is a leading cause of immobilisation post-operatively. National guidance advises appropriate fluid resuscitation and review of polypharmacy when indicated (British Orthopaedic Association, 2007). This quality improvement project aimed to reduce post-operative hypotension and improve day one post-operative mobilisation in NOFF patients.

Method

Three months of NOFF patients were retrospectively reviewed pre-intervention. Those who did not receive surgical intervention were excluded. The proportion of NOFF patients that were unable to mobilise due to post-operative hypotension on day one was identified. We reviewed if intravenous fluids were given pre-operatively and if anti-hypertensives were held. An intervention was then implemented including educational posters and teaching sessions for doctors and nurses to encourage prescription of fluids on admission, holding of antihypertensives pre-operatively and detection and escalation of oliguria or hypotension post-operatively. Data were then re-collected in a three-month period post-intervention to ascertain if there was any change in practice.

Results

70 patients underwent NOFF repair pre-intervention compared to 54 patients post-intervention. There was a decrease in the proportion of patients unable to mobilise day one post-operatively due to hypotension from 15.7% pre-intervention to 9.3% post-intervention. There was an increase in the proportion of patients who received pre-operative intravenous fluids from 64.3% pre-intervention to 77.8% post-intervention. Of those patients who took anti-hypertensive medication, a higher proportion had this suspended pre-operatively, increasing from 82.9% pre-intervention to 88.2% post-intervention.

Conclusion

Simple educational interventions can reduce post-operative hypotension in NOFF patients. Developing local guidelines may facilitate persistent clinical change, as improvements following poster distribution and teaching sessions may be transient.

INTRODUCTION:

University Hospital Southampton (UHS) and Saints Foundation (SF) have partnered to test and deliver rehabilitation to hospitalised older adults via a non-registered Exercise Practitioner (EP) to promote physical activity (PA) and address hospital associated deconditioning. Now in its third phase, the project has evolved in response to patient and staff feedback. It delivers regular gym-based exercise classes and additional interventions, which have maintained or improved patients’ dependency levels on discharge.

METHODOLOGY:

From September 2023, the EP has delivered daily gym-based group interventions as well as 1:1 rehabilitation to hospitalised older adults. In addition, exercise prescription education for staff and signposting to community-based interventions is provided. Interventions take place in the acute therapy gym or wards.

RESULTS:

Between October 2023 and February 2024, the EP reviewed 115 patients, with a mean age of 86yrs. 90 (78%) underwent group-based intervention whereas 25 (22%) received 1:1 input. 100 (87%) patients maintained or improved their predicted to actual discharge destination, compared to 13 (11%) whose physical capability declined and 2 (2%) who died. 20 (17%) were readmitted within 30 days of discharge. Elderly Mobility Scores (EMS) improved from a mean of 13.42 to 13.97. Most patients were reviewed twice or more. Most patients (79% after 2 interventions) maintained a 4m gait speed score of >0.8m/s. Patient satisfaction and confidence in function rated high.

CONCLUSION:

Intervention via a non-registered EP continues to have a positive impact on older adults’ ability to maintain or improve function during an acute hospital stay. Factors such as outbreaks of infectious illness, staff absence and vacancies and high patient acuity prevent more frequent EP led intervention. Although overall strength and functional gains are limited, patient confidence in function remains high. Our future aim is to expand the project across UHS and bridge the gap to community rehabilitation services.

Hip fractures are a major public health issue due to ageing populations and Ireland has one of the highest hip fracture rates in Europe1. The cost of acute hip fracture care was 48.5 million euros in 20221. The Irish Hip Fracture Database in 2022 revealed that 84% of people presenting to acute hospitals with hip fracture were admitted from home, however only 29% were discharged directly home1. NICE guidelines recommend early supported discharge for patients who are medically stable and mentally fit to participate with rehabilitation and who can transfer and mobilise short distance but have not yet achieved their full potential2. The National Integrated Care Programme for Older Persons (NICPOP) improves the life of older people by providing access to integrated care and support that is planned around their needs and choices, supporting them to live well in their own homes3. This poster outlines the rehabilitation pathway established by the SJH ICPOP team to provide early supported discharge for hip fracture patients.

Purpose

To investigate physiotherapists’ perspectives of effective community provision following hip fracture.

Methods

Qualitative semi-structured interviews were conducted with 17 community physiotherapists across England. Thematic analysis drawing on the Theoretical Domains Framework identified barriers and facilitators to implementation of effective provision. Interviews were complemented by process mapping community provision in one London borough, to identify points of care where suggested interventions are in place and/or could be implemented.

Results

Four themes were identified: ineffective coordination of care systems, ineffective patient stratification, insufficient staff recruitment and retention approaches and inhibitory fear avoidance behaviours. To enhance care coordination, participants suggested improving access to social services and occupational therapists, maximising multidisciplinary communication through online notation, extended physiotherapy roles, orthopaedic-specific roles and seven-day working. Participants advised the importance of stratifying patients on receipt of referrals, at assessment and into appropriately matched interventions. To mitigate insufficient staff recruitment and retention, participants proposed return-to-practice streams, apprenticeship schemes, university engagement, combined acute-community rotations and improving job description advertisements. To reduce effects of fear avoidance behaviour on rehabilitation, participants proposed the use of patient-specific goals, patient and carer education, staff education in psychological strategies or community psychologist access. Process mapping of one London borough identified points of care where suggested interventions to overcome barriers were in place and/or could be implemented.

Conclusion

Physiotherapists propose that effective provision of community physiotherapy following hip fracture could be improved by refining care coordination, utilising stratification techniques, employing enhanced recruitment and retainment strategies and addressing fear avoidance behaviours.

Introduction

People recently diagnosed with Parkinson’s disease (PD) may withdraw from physical activity because of PD symptoms or loss of confidence. We are conducting a feasibility trial of a remote physiotherapy intervention. To gain a broader understanding of attitudes to physical activity and physiotherapy, we surveyed people with early PD in UK.

Methods

We developed a questionnaire (JISC Online Surveys) about physical activity and remote physiotherapy. This was distributed on paper to local Parkinson’s UK groups, and online via Parkinson’s UK newsletter and social media. 

Results

We received 274 valid responses. The most frequent age category was 60-69 years (69%), and just over half of respondents were male (53%). Respondents of diverse ethnicities amounted to 2% of the total sample. For physical activity, the majority of participants reported a high or average level of physical activity, with only 11% reporting a low level. The majority of participants reported that regular exercise was extremely or very important for keeping well with PD. When asked about barriers to being active, the most common response was apathy (29%), followed by difficulties due to PD symptoms and feeling exhausted. These barriers may be amenable to physiotherapy intervention, and we asked participants about their experience of physiotherapy. 47% reported that they had never had physiotherapy for PD; the remainder ranged from single assessment to more than one course of physiotherapy. In terms of telemedicine, 36% reported having a videoconsultation with a doctor or therapist in the last year, with the majority of these participants reporting a good experience; whereas 7% reported concerns with technology.

Discussion

The majority of respondents were enthusiastic about physical activity and believed this was helpful for their wellbeing. Barriers to exercise may be amenable to physiotherapy intervention. Digital monitoring and telemedicine were acceptable to many respondents.

Introduction: Hip Fracture Surgery (HFS) can result in balance impairment which is associated with an increased risk of falls in the elderly as well as limitations in their mobility. Balanced Training (BT) is a rehabilitation method used aiming to minimize the balance impairments post HFS. BT options include stepping, balance task-specific exercise, standing on one leg, yoga.

Our main outcome is to evaluate the effect of BT on the physical functioning of elderly patients post an HFS.

Methods: We conducted a systematic review using the PubMed-Medline, Cochrane Library and Embase databases to locate randomized controlled trials which compared BT with standard care post HFS. The Cochrane’ Library Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used as our template for the review.

Results: Overall, nine randomized controlled trials were selected, comprising a total of 712 patients, all aged 65 years of age and older. With regards to the type of BT rehabilitation: four trials used step-ups (n=500), three trials used balance task-specific exercise (n=170) and two studies used standing on one leg (n=42). The BT group demonstrated improvement in physical functioning post HFS compared to the control group (Standardized Mean Difference (SMD) = 0.410). Moreover, all functional parameters which include, lower limb strength, performance task and health related quality of life, were also improved in the BT group.

Conclusion: Evidently, the results demonstrate an improvement of physical functioning by BT post HFS. Furthermore, the positive effects on all functioning parameters were apparent. As a result, the implementation of BT in postoperative rehabilitation programs in elderly patients with hip fractures should be considered. References: Monticone M, Ambrosini E, Brunati R, et al. How balance task-specific training contributes to improving physical function in older subjects undergoing rehabilitation following hip fracture: a randomized controlled trial. Clin Rehabil. 2018;32:340–351