Frail Elderly, Inpatients Clinical Trial
Official title:
Implementing Grip Strength Measurement Into Routine Clinical Practice; a Feasibility Study (GRImP)
Hand grip strength (GS) is a non-invasive marker of whole body skeletal muscle strength and function used in research and recommended as a simple inexpensive measure suitable for clinical use. Research has shown that low GS in hospital inpatients is associated with poor healthcare outcomes including increased postoperative complications, longer length of stay, increased functional limitations and disability. Measuring GS on admission to hospital has the potential to identify people at risk of poor healthcare outcomes allowing early intervention including focus on nutrition and mobility. Yet, GS measurement is not routinely used in clinical practice. The aim of this study is to evaluate the implementation of GS measurement into routine clinical practice in Medicine for Older People wards at UHS.
This implementation research involves mixed methods combining qualitative and quantitative
elements. The first preliminary part of the study will define the current baseline practice
in the MOP wards in University Hospital Southampton (UHS) with regard to the identification
of patients at high risk of poor healthcare outcomes, inpatients' nutritional care and
management of their mobility. For this purpose, an ethnographic approach (involving
interviews, focus groups, and audit of clinical records) will be followed. Understanding how
the healthcare system works will enable justification and integration of GS measurement in
the routine practice in an effective way. Participants and situations will be sampled on a
purposive basis which means "cases/participants are sampled in a strategic way to best answer
the research question". Single in-depth semi structured interviews will be conducted with
different groups of healthcare staff with different levels of experiences and roles including
consultants, junior doctors, ward sisters, dieticians, physiotherapists, and therapy
assistants (a total of 10-15 healthcare staff members). The investigators will also conduct
focus groups with nursing staff from the 5 wards, with nurses of similar seniority in each
group to encourage free discussion (approximately 15-20 nurses divided into 4-5 focus groups)
to gain an understanding of their shared practice.
The medical notes for the patients in the first 1-3 beds in each bay in the 5 wards will be
examined (approximately 54 records). Basic information about the patient such as: age,
gender, date of admission, domicile status, and reasons for admission will be first
extracted. Then investigators will check the records to extract any information within the
first 2-3 days of admission about risk assessment measures and what could indicate risk
factors for poor healthcare outcomes. In addition, the number of and reasons for referrals
weekly for the last 3 months to the dietetic team will be abstracted from the E-referral
system. The number of prescribed oral nutritional supplements (ONS) will be also calculated
weekly for the last 3 months from the electronic prescribing system. These figures are
important for later analysis and comparison in order to assess changes in routine practice.
The second part of the research involves developing a training programme on measuring GS and
creation of a care plan for older patients with low GS levels. Then, the nursing, medical and
therapy staff in 5 wards in the MOP department will be trained in the measurement of grip
strength and interpretation of grip strength values. There are approximately 150 nursing
staff in MOP across the 5 wards, all of whom will be trained over a period of 3 months in GS
measurement in groups of 5-10 each. Additional training sessions will be provided to junior
doctors, consultants and therapy staff taking the opportunity to incorporate this into
regular educational sessions where possible. The time and date of the training sessions will
be defined and agreed liaising with the training lead in the MOP to avoid any disruption to
the daily tasks of the MOP staff. The training session will last for approximately 1 hour. At
the end of each session, participants will be asked to evaluate the training session using
5-points rating scale and give feedback. Nurses attending the training session will be asked
as part of the training program to measure GS of a colleague according to the standard
protocol as an assessment of their competency to measure GS of patients.
Implementation of GS should be start soon after completing the first training session in each
ward. GS will be measured on all patients admitted to the MOP wards within 1-3 days of
admission by a ward nurse. Only patients who are unable to squeeze the dynamometer handle
such as patients with arthritis or who are very ill will be excluded. Grip strength will be
measured by the ward nurse using a Jamar dynamometer by asking the patient to squeeze with
each hand twice, starting with the right hand using the standardised protocol. A brief break
of approximately 1 minute will be allowed between each squeeze. The maximum GS measurement
will be recorded. A total of 5 Jamar dynamometers will be available for this study, one in
each ward. The maximum GS values will be coded in two categories: score 1 representing values
less than 27 kg for men and less than 16 kg for women which refers to patients at high risk
of poor health outcomes, and score 2 representing values ≥27 kg for men and ≥16 kg for women
representing lower risk. Patients who have low maximum GS values (men < 27 kg and women <16
kg) or those who are unable to perform the test will receive a care plan. The care plan will
focus on review of dietary energy and protein intake and any need for oral nutritional
supplements or dietetic review, and review of mobility with any need for physiotherapy review
with regard to progressive resistance exercises to increase muscle strength.
During the implementation process, monitoring and evaluation of the outcomes of
implementation which are referred to by the World Health Organisation (WHO) as
"implementation outcome variables" will include assessing: acceptability of GS measurement,
its adoption, coverage, fidelity, and costs.
Patients and staff acceptability will be assessed by conducting qualitative research
(interviews or focus groups). A sample of 10-15 patients and 10-20 MOP staff is deemed to be
enough to gain an understanding of their views and experience of GS measurement. Staff
interviews will also assist understanding how GS routine implementation has been adopted and
initiated in each of the five wards. Random weekly visits to MOP will be conducted to check
fidelity and continuing staff competency on measuring GS as well as to audit the number of
the number and proportion of patients who have their GS measured and those who have received
a care plan in each ward. Coverage of GS implementation will be measured by calculating in
the total number and proportion of patients who have their GS measured and those who have
received a care plan in MOP within 6 months of routine implementation.
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