Development of a Frailty Index in the Irish Hip Fracture Database

INTRODUCTION

In older people, hip fracture can lead to adverse outcomes. Frailty, capturing biological age and vulnerability to stressors, can indicate those at higher risk. We derived a frailty index (FI) in the Irish Hip Fracture Database (IHFD) and explored associations with prolonged length of hospital stay (LOS ≥ 30 days), delirium, inpatient mortality and new nursing home admission. We assessed whether the FI predicted those outcomes independently of age, sex and pre-operative American Society of Anaesthesiology (ASA) score.

MATERIALS AND METHODS

A 21-item FI was constructed with 17 dichotomous co-morbidities, three 4-level ordinal pre-morbid functional variables (difficulty with indoor mobility, outdoor mobility, and shopping) and nursing home provenance (yes/no). The FI was computed as the proportion of items present and divided into tertiles (low, medium, high risk). Independent associations between FI and outcomes were explored with logistic regression, from which we extracted adjusted Odds Ratios (aOR) and Areas Under the Curve (AUC).

RESULTS

From 2017 to 2020, the IHFD included 14,615 hip fracture admissions, mean (SD) age 80.4 (8.8), 68.9% women. Complete FI data were available for 12,502 (85.5%). By FI tertile (low to high risk), prolonged LOS proportions were 5.9%, 16.1% and 23.1%; delirium 5.5%, 13.5% and 17.6%; inpatient mortality 0.6%, 3.3% and 10.1%; and new nursing home admission 2.2%, 5.9% and 11.3%. All associations were statistically significant (p < 0.001) independently of age and sex. AUC analyses showed that the FI score, added to age, sex, and ASA score, significantly improved the prediction of delirium and new nursing home admission (p < 0.05), and especially prolonged LOS and inpatient mortality (p < 0.001).

CONCLUSIONS

A 21-item FI in the IHFD was a significant predictor of outcomes and added value to traditional risk markers. The utility of a routinely derived FI to more effectively direct limited orthogeriatric resources requires prospective investigation.

Co-designing Being Your Best program-A holistic approach to frailty in older community dwelling Australians

Frailty is a condition characterised by increased vulnerability and decline of physical and cognitive reserves, most often affecting older people. This can lead to a cascade of repeated hospitalisations, further decline and ultimately loss of independence. Frailty and pre-frailty are modifiable; interventions such as physical exercise, cognitive training, social connection and improved nutrition, especially in a group setting, can mitigate frailty. Existing healthcare guidelines for managing frailty focus predominantly on falls, delirium, acute confusion and immobility. Uptake of referrals to services following hospital discharge is sub-optimal, indicating that a more proactive, person-centred and integrated approach to frailty is required. The aim was to co-design a program to help pre-frail and frail older people return to their homes following hospital discharge by increasing resilience and promoting independence. We engaged healthcare consumers, and healthcare professionals from three tertiary hospitals in metropolitan Melbourne (Alfred Hospital, Monash Health and Cabrini Health), and from Bolton Clarke home-based support services. Co-design is a process whereby the input of service consumers is included in the development of a program. In the healthcare sector, co-design involves discussions with healthcare consumers alongside healthcare professionals to identify issues and build knowledge to ultimately work on improving the healthcare system. From co-design sessions with 23 healthcare consumers and 17 healthcare professionals, it was apparent that frailty was perceived to affect physical and mental well-being. The co-design process resulted in refinement of the Being Your Best program to incorporate a holistic approach, addressing four domains supported by research evidence, to improve health and well-being through community- or home-based physical activity, cognitive training, social support and nutritional support. Being Your Best was developed in consultation with older people with lived experience as well as healthcare professionals and aims to mitigate the effects of frailty, and will now be tested for feasibility and acceptability.

Factors affecting missed nursing care in hospitalized frail older adults in the medical wards: a qualitative study

BACKGROUND

Frail older adults who are hospitalized, are more likely to experience missed nursing care (MNC) due to high care needs, communication problems, and complexity of nursing care. We conducted a qualitative study to examine the factors affecting MNC among hospitalized frail older adults in the medical units.

METHODS

This qualitative study was carried using the conventional content analysis approach in three teaching hospitals. Semi-structured interviews were conducted with 17 nurses through purposive and snowball sampling. The inclusion criteria for the nurses were: at least two years of clinical work experience on a medical ward, caring for frail older people in hospital and willingness to participate. Data were analyzed in accordance with the process described by Graneheim and Lundman. In addition, trustworthiness of the study was assessed using the criteria proposed by Lincoln and Guba.

RESULTS

In general, 20 interviews were conducted with nurses. A total of 1320 primary codes were extracted, which were classified into two main categories: MNC aggravating and moderating factors. Factors such as "age-unfriendly structure," "inefficient care," and "frailty of older adults" could increase the risk of MNC. In addition, factors such as "support capabilities" and "ethical and legal requirements" will moderate MNC.

CONCLUSIONS

Hospitalized frail older adults are more at risk of MNC due to high care needs, communication problems, and nursing care complexity. Nursing managers can take practical steps to improve the quality of care by addressing the aggravating and moderating factors of MNC. In addition, nurses with a humanistic perspective who understand the multidimensional problems of frail older adults and pay attention to their weakness in expressing needs, can create a better experience for them in the hospital and improve patient safety.

Enabling public, patient and practitioner involvement in co-designing frailty pathways in the acute care setting

BACKGROUND

Although not an inevitable part of ageing, frailty is an increasingly common condition in older people. Frail older patients are particularly vulnerable to the adverse effects of hospitalisation, including deconditioning, immobility and loss of independence (Chong et al, J Am Med Dir Assoc 18:638.e7-638.e11, 2017). The 'Systematic Approach to improving care for Frail older patients' (SAFE) study co-designed, with public and patient representatives, quality improvement initiatives aimed at enhancing the delivery of care to frail older patients within an acute hospital setting. This paper describes quality improvement initiatives which resulted from a co-design process aiming to improve service delivery in the acute setting for frail older people. These improvement initiatives were aligned to five priority areas identified by patients and public representatives.

METHODS

The co-design work was supported by four pillars of effective and meaningful public and patient representative (PPR) involvement in health research (Bombard et al, Implement Sci 13:98, 2018; Black et al, J Health Serv Res Policy 23:158-67, 2018). These pillars were: research environment and receptive contexts; expectations and role clarity; support for participation and inclusive representation and; commitment to the value of co-learning involving institutional leadership.

RESULTS

Five priority areas were identified by the co-design team for targeted quality improvement initiatives: Collaboration along the integrated care continuum; continence care; improved mobility; access to food and hydration and improved patient information. These priority areas and the responding quality improvement initiatives are discussed in relation to patient-centred outcomes for enhanced care delivery for frail older people in an acute hospital setting.

CONCLUSIONS

The co-design approach to quality improvement places patient-centred outcomes such as dignity, identity, respectful communication as well as independence as key drivers for implementation. Enhanced inter-personal communication was consistently emphasised by the co-design team and much of the quality improvement initiatives target more effective, respectful and clear communication between healthcare personnel and patients. Measurement and evaluation of these patient-centred outcomes, while challenging, should be prioritised in the implementation of quality improvement initiatives. Adequate resourcing and administrative commitment pose the greatest challenges to the sustainability of the interventions developed along the SAFE pathways. The inclusion of organisational leadership in the co-design and implementation teams is a critical factor in the success of interventions targeting service delivery and quality improvement.