Rehabilitation

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.

Introduction

Highly challenging, regular strength and balance exercise classes (SBE) reduces fall risk but there are few options for long-term continuation. SBE could be delivered by the voluntary sector, but care is needed to ensure good fidelity. The feasibility of delivering evidence-based SBE outside the governance of health services is unclear. A voluntary sector-led weekly SBE class ‘Strong and Steady (S&S)’, led by a level 4 qualified postural stability and funded via grants and fees, was set up in December 2022 alongside an existing community coffee morning.

Methods

Baseline measures and adherence were collected for all who commenced S&S. Two classes were observed using a standardised fidelity checklist. Interviews and focus groups were undertaken with class participants, a previous participant, the exercise instructor and lead volunteer.

Results

Since December 2022, 24 participants aged 59-95 (63% female) self-referred to S&S. Baseline measures, collected in 100% of assessments, (timed up and go, four-step balance scale and 60-second sit-to-stand) indicated performance slightly below age-matched norms with the exception of falls efficacy (FES-I). Three participants dropped out (1 died) and adherence was 67%. Fidelity in both observed classes was good (mean score 21/24). Four themes emerged from thematic analysis of all the interviews and focus groups: 1. S&S was associated with a range of benefits to health and wellbeing that contributed to participant uptake, adherence and to staff satisfaction. 2. Limiting class size is necessary to maintain fidelity and safety. 3. The social element of the class was a key driver in participation. 4. The participants of S&S had high levels of self-efficacy and motivation to participate in exercise

Conclusion

Delivering SBE via the voluntary sector is feasible and can be delivered with good fidelity. The provision tends to attract people who have high levels of self-efficacy and motivation to exercise.

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.

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.

Hip fractures are fractures involving the femoral head, neck or proximal shaft. They most often occur in frail, osteoporotic elderly patients following falls. Hip fractures are associated with a 30 day mortality rate of 10% and a 1 year mortality rate of approximately 30%. NICE and NHFD advise prompt mobilisation post surgery - with patients being mobilised by the day after surgery at the latest: 1. Nice Guidelines Hip Fracture in Adults; Quality statement 6: Rehabilitation after surgery 2. NHFD KPI 4 – prompt mobilisation after surgery We carried out two audit cycles assessing the mobilisation rate of patients by the day after hip arthroplasty, at Bradford Royal Infirmary. In the first cycle, from 23 eligible patients, we found only 15 (65%) were mobilised within a day of surgery. These patients had a reduced length of stay compared to the patients not mobilised by the day after surgery (15.1 vs 18.1 days). As per our data, the reasons for delayed mobilisation included 1. pain (suggest early and regular analgesia), and 2. system miss (discussed with local physiotherapy team). After four months we reaudited. Of 23 eligible patients we found an improvement in patients being mobilised - 17 patients (74%) were mobilised within a day of surgery. Once again length of stay was less in the patients who had been mobilised (21.2 vs 29.7 days). Similar reasons for delayed mobilisation remained. In summary, our interventions improved the promptness of mobilisation in patients who had undergone hip arthroplasty. This led to a reduced duration of inpatient stay and better patient outcomes. Audit limitations included population size.

Introduction

People living with dementia and MCI progressively lose abilities, through increasing cognitive impairment, co-morbidities, inactivity, acute illnesses and injuries. Rehabilitation therapy may reduce disability and falls and increase resilience.

Methods

We co-produced a therapy intervention, comprising strength, balance and dual-task exercises, functional activity training and promoting community access, providing up to 50 therapy sessions, delivered over 12 months and underpinned by a behaviour change strategy. We evaluated the intervention in a 5-site multi-centred Randomised Controlled Trial, against a brief assessment control. Participants had a diagnosis of dementia or MCI, Montreal Cognitive Assessment (MoCA) between 13 and 25. Primary outcome was the Disability Assessment in Dementia (DAD), an ADL score, after 12 months, alongside a battery of other health status measures. The COVID-19 pandemic necessitated modifications.

Results

We recruited 365 participants, 42% female. Median age was 81 years (range 65-95), MoCA 20 (13-26), DAD 82 (5-100). Baseline balance between groups was good. Participants were predominantly white and socioeconomically advantaged. Intervention group participants received a median of 31 (IQR 22-40) session and undertook and additional mean 121 minutes of exercise per week. Assessed fidelity was good. 290 (79%) were followed up. There were no significant differences in DAD score (adjusted mean difference -1.3/100, 95% CI -5.2 to +2.6; effect size (d) -0.06; -0.26 to 0.15; p=0.5), physical activity, balance, quality of life, cognition or a range of other measures. Upper 95% confidence intervals excluded even small benefits. Rate of falling reduced by 22% (Rate Ratio=0.78; 0.46 to 1.3; p=0.3), but this was not statistically significant.

Conclusions

The intensive PrAISED intervention did not improve measured outcomes. It may be impossible to reduce the rate of functional decline in dementia. Alternatively, the pandemic may have distorted outcomes or participants may have been too advantaged to benefit. There may have been unmeasured psycho-social benefits.

BACKGROUND

Physical rehabilitation is related to better surgical and medical outcomes for patients (WHO, 2021). In hospitals, the role of the rehab team is essential to promote faster and better recovery and to prevent falls (Brett et al., 2019). We wanted to review the communication between the rehab, nursing, and medical team to aid discharge planning. Better communication can reduce repetition.

METHODS

A baseline survey was given to doctors, nurses, and rehab staff in a geriatric ward to review communication. The intervention was an A4 template highlighting the patients’ baseline and current function, which was placed by the bedside. A repeat survey was done to evaluate the effectiveness.

RESULTS

Survey 1 had 13 participants. Survey 2 had 25 participants. At least 90% of doctors and nurses strongly agree that they need to know patients’ ability to transfer, mobilise, wash, dress and falls risks. One hundred per cent of the rehab team agrees that patients’ rehab status is not clearly communicated between different members of the MDT which improved to 71.4% after the intervention. After the intervention, 20% of doctors agree that they struggle to find rehab status information, compared to 66.6% before, and 60% of doctors agree that they still find themselves asking other members of the MDT about patients’ rehab status, compared to only 37.5% of nurses.

CONCLUSION

To know patients’ rehab status is extremely important for their medical management, nursing management, and for their safety. A simple intervention had improved the awareness of patient rehab status, reducing time wasted on repetition. Another cycle to further improve communication by a teaching session will be conducted at each rotation to ensure sustainability.