Adjunctive electrophysical therapies used in addition to land-based exercise therapy for osteoarthritis of the hip or knee: A systematic review and meta-analysis

Objectives

To review evidence for effectiveness of electrophysical therapies (EPTs), used adjunctively with land-based exercise therapy, for hip or knee osteoarthritis (OA), compared with 1) placebo EPTs delivered with land-based exercise therapy or 2) land-based exercise therapy only.

Methods

Six databases were searched up to October 2023 for randomised controlled trials (RCTs)/quasi-RCTs comparing adjunctive EPTs alongside land-based exercise therapy versus 1) placebo EPTs alongside land-based exercise, or 2) land-based exercise in hip or knee OA. Outcomes included pain, function, quality of life, global assessment and adverse events. Risk of bias and overall certainty of evidence were assessed. We back-translated significant Standardised Mean Differences (SMDs) to common scales: 2 points/15% on a 0-10 Numerical Pain Rating Scale and 6 points/15% on the WOMAC physical function subscale.

Results

Forty studies (2831 patients) evaluated nine different EPTs for knee OA. Medium-term effects (up to 6 months) were evaluated in seven trials, and one evaluated long-term effects (>6 months). Adverse events were reported in one trial. Adjunctive laser therapy may confer short-term effects on pain (SMD -0.68, 95%CI -1.03 to -0.34; mean difference (MD) 1.18 points (95% CI -1.78 to -0.59) and physical function (SMD -0.60, 95%CI -0.88 to -0.34; MD 12.95 (95%CI -20.05 to -5.86)) compared to placebo EPTs, based on very low-certainty evidence. No other EPTs (TENS, interferential, heat, shockwave, shortwave, ultrasound, EMG biofeedback, NMES) showed clinically significant effects compared to placebo/exercise, or exercise only.

Conclusions

Very low-certainty evidence supports laser therapy used adjunctively with exercise for short-term improvement in pain and function. No other EPTs demonstrated clinically meaningful effects.

'If he thought that I was going to go and hurt myself, he had another thing coming': Treatment experiences of those with large to massive rotator cuff tears and the perspectives of healthcare practitioners

OBJECTIVE

To explore the treatment experiences of those diagnosed with large to massive rotator cuff tears and the perspectives of healthcare practitioners providing their care.

DESIGN

A qualitative descriptive study using reflexive thematic analysis.

SETTING

In-person focus groups were undertaken in a clinical setting (private practice [n = 1]; public outpatient [n = 2]). Semi-structured interviews were conducted online via Microsoft Teams.

PARTICIPANTS

Patients diagnosed with these tears (n = 12) and healthcare practitioners (n = 11).

RESULTS

Two interlinking themes were identified based on the care received and provided for patients with symptomatic large to massive rotator cuff tears:1) Positive treatment experiences and management: Education, clear communication and reassurance around prognosis were the foundation of positive patient-clinician care. Sub-themes of pain relief, exercise prescription and confidence in their pathway underpinned this experience. This proficiency in care was affirmed by some healthcare practitioners who spoke about the importance of confidence and experience in their management plan even in times of poor progress.2) Negative treatment experiences and management: Uncertainty, delays and exacerbation of pain flawed the patient-clinician care. Sub-themes of inappropriate pain relief, inappropriate exercise prescription and uncertainty impacted their care. Some healthcare practitioners acknowledged knowledge gaps led to uncertainty especially when choosing the next step of care and were quick to escalate care to deflect this uncertainty.

CONCLUSIONS

The findings suggest discordance exists between the patient's experiences and expectations when the delivery of care was by less experienced and confident healthcare practitioners in the management of this condition. This highlights the need for improved education and support for healthcare practitioners.

Transitioning to home and beyond following stroke: a prospective cohort study of outcomes and needs

INTRODUCTION

Understanding of the needs of people with stroke at hospital discharge and in the first six-months is limited. This study aim was to profile and document the needs of people with stroke at hospital discharge to home and thereafter.

METHODS

A prospective cohort study recruiting individuals with stroke, from three hospitals, who transitioned home, either directly, through rehabilitation, or with early supported discharge teams. Their outcomes (global-health, cognition, function, quality of life, needs) were described using validated questionnaires and a needs survey, at 7-10 days, and at 3-, and 6-months, post-discharge.

RESULTS

72 patients were available at hospital discharge; mean age 70 (SD 13); 61% female; median NIHSS score of 4 (IQR 0-20). 62 (86%), 54 (75%), and 45 (63%) individuals were available respectively at each data collection time-point. Perceived disability was considerable at hospital discharge (51% with mRS ≥ 3), and while it improved at 3-months, it increased thereafter (35% with mRS ≥ 3 at 6-months). Mean physical health and social functioning were "fair" at hospital discharge and ongoing; while HR-QOL, although improved over time, remained impaired at 6-months (0.69+/-0.28). At 6-months cognitive impairment was present in 40%. Unmet needs included involvement in transition planning and care decisions, with ongoing rehabilitation, information, and support needs. The median number of unmet needs at discharge to home was four (range:1-9), and three (range:1-7) at 6-months.

CONCLUSION

Stroke community reintegration is challenging for people with stroke and their families, with high levels of unmet need. Profiling outcomes and unmet needs for people with stroke at hospital-to-home transition and onwards are crucial for shaping the development of effective support interventions to be delivered at this juncture.

ISRCTN REGISTRATION

02/08/2022; ISRCTN44633579.

Older adults experience of transition to the community from the emergency department: a qualitative evidence synthesis

AIM

Older adults comprise a growing proportion of Emergency Department (ED) attendees and are vulnerable to adverse outcomes following an ED visit including ED reattendance within 30 days. Interventions to reduce older adults' risk of adverse outcomes following an ED attendance are proliferating and often focus on improving the transition from the ED to the community. To optimise the effectiveness of interventions it is important to determine how older adults experience the transition from the ED to the community. This study aims to systematically review and synthesise qualitative studies reporting older adults' experiences of transition to the community from the ED.

METHODS

Six databases (Academic Search Complete, CINAHL, MEDLINE, PsycARTICLES, PsycINFO, and Social Science Full Text) were searched in March 2022 and 2023. A seven-step approach to meta-ethnography, as described by Noblit and Hare, was used to synthesise findings across included studies. The methodological quality of the included studies was appraised using the 10-item Critical Appraisal Skills Programme (CASP) checklist for qualitative research. A study protocol was registered on PROSPERO (Registration: CRD42022287990).

FINDINGS

Ten studies were included, and synthesis led to the development of five themes. Unresolved symptoms reported by older adults on discharge impact their ability to manage at home (theme 1). Limited community services and unresolved symptoms drive early ED reattendance for some older adults (theme 2). Although older adults value practical support and assistance transporting home from the ED this is infrequently provided (theme 3). Accessible health information and interactions are important for understanding and self-managing health conditions on discharge from the ED (theme 4). Fragmented Care between ED and community is common, stressful and impacts on older adult's ability to manage health conditions (theme 5). A line of argument synthesis integrated these themes into one overarching concept; after an ED visit older adults often struggle to manage changed, complex, health and care needs at home, in the absence of comprehensive support and guidance.

DISCUSSION/ CONCLUSION

Key areas for consideration in future service and intervention development are identified in this study; ED healthcare providers should adapt their communication to the needs of older adults, provide accessible information and explicitly address expectations about symptom resolution during discharge planning. Concurrently, community health services need to be responsive to older adults' changed health and care needs after an ED visit to achieve care integration. Those developing transitional care interventions should consider older adults needs for integration of care, symptom management, clear communication and information from providers and desire to return to daily life.

Healthcare professionals' experiences of delivering a stroke Early Supported Discharge service - An example from Ireland

OBJECTIVE

To explore healthcare professionals' experiences of the development and delivery of Early Supported Discharge for people after stroke, including experiences of the COVID-19 pandemic.

DESIGN

Qualitative descriptive study using one-to-one semi-structured interviews. Data were analysed using reflexive thematic analysis.

SETTING

Nine Early Supported Discharge service sites in Ireland.

PARTICIPANTS

Purposive sampling identified 16 healthcare professionals.

RESULTS

Five key themes were identified (1) Un-coordinated development of services, (2) Staff shortages limit the potential of Early Supported Discharge, (3) Limited utilisation of telerehabilitation post COVID-19 pandemic, (4) Families need information and support, and (5) Early Supported Discharge involves collaboration with people after stroke and their families.

CONCLUSIONS

Findings highlight how Early Supported Discharge services adapted during the COVID-19 pandemic and how gaps in the service impacts on service delivery. Practice implications include the need to address staff recruitment and retention issues to prevent service shortages and ensure consistent access to psychology services. Early Supported Discharge services should continue to work closely with families and address their information and support needs. Future research on how telerehabilitation can optimally be deployed and the impact of therapy assistants in Early Supported Discharge is needed.

Effectiveness of occupational therapy interventions on function and satisfaction with occupational performance among adults with conditions of the hand, wrist, and forearm: a protocol for a systematic review

Background

Functional hand use post injury is important in enabling a person's engagement in daily living tasks. Without proper treatment, there may be difficulties in self-care, engaging in job roles, or leisure pursuits. Occupational therapists are key health care practitioners for people with upper limb conditions. This systematic review aims to appraise and summarise current evidence regarding effectiveness of occupational therapy interventions among adults with conditions of the hand, wrist, and forearm.

Methods

A systematic review of randomised control trials and quasi randomised controlled trials will be completed. MEDLINE OVID, CINAHL, CENTRAL, COCHRANE, PUBMED and EMBASE databases will be systematically searched. Grey literature will be searched for via Google Scholar. Studies will be included if they include provision of occupational therapy to adults with a hand, wrist, or forearm condition when compared to treatment as usual or an alternative treatment option. The primary outcome will be function. Secondary outcomes will include satisfaction with occupational performance, quality of life, pain experience, and participation. The Brief International Classification of Functioning, Disability and Health (ICF) Core Set for Hand Conditions will be used to categorise outcomes. The Cochrane Risk of Bias 2 (RoB 2) tool and the Grading of Recommendations Assessment, Development, and Evaluations (GRADE) framework will be utilised to assess quality. A pooled meta- analysis will be completed using RevMan, depending on the uniformity and availability of data.

Results

This review aims to synthesise high quality evidence to identify the effectiveness of occupational therapy interventions with patients with a hand, wrist, or forearm condition, categorising outcomes in relation to the ICF Core Set for Hand Conditions.

Conclusions

By synthesising the evidence there is potential for improved evidence base for clinicians; improved outcomes for patients; as well as potential economic benefit.This study is registered with PROSPERO: CRD42022337070.

Early supported discharge for older adults admitted to hospital after orthopaedic surgery: a systematic review and meta-analysis

BACKGROUND

Early supported discharge (ESD) aims to link acute and community care, allowing hospital inpatients to return home, continuing to receive the necessary input from healthcare professionals that they would otherwise receive in hospital. Existing literature demonstrates the concept having a reduced length of stay in stroke inpatients and medical older adults. This systematic review aims to explore the totality of evidence for the use of ESD in older adults hospitalised with orthopaedic complaints.

METHODS

A literature search of Cochrane Central Register of Controlled Trials in the Cochrane Library (CENTRAL), EMBASE, CINAHL and MEDLINE in EBSCO was carried out on January 10th, 2024. Randomised controlled trials or quasi-randomised controlled trials were the study designs included. For quality assessment, The Cochrane Risk of Bias Tool 2.0 was used and GRADE was applied to evaluate the certainty of evidence. Acute hospital length of stay was the primary outcome. Secondary outcomes included the numbers of fallers and function. A pooled meta-analysis was conducted using RevMan software 5.4.1.

RESULTS

Seven studies with a population of older adults post orthopaedic surgery met inclusion criteria, with five studies included in the meta-analysis. Study quality was predominantly of a high risk of bias. Statistically significant effects favouring ESD interventions were only seen in terms of length of stay (FEM, MD = -5.57, 95% CI -7.07 to -4.08, I2 = 0%). No statistically significant effects favouring ESD interventions were established in secondary outcomes.

CONCLUSION

In the older adult population with orthopaedic complaints, ESD can have a statistically significant impact in reducing hospital length of stay. This review identifies an insufficient existing evidence base to establish the key benefits of ESD for this population group. There is a need for further higher quality research in the area, with standardised interventions and outcome measures used.

Comprehensive Geriatric Assessment in the Emergency Department: A Prospective Cohort Study of Process, Clinical, and Patient-Reported Outcomes

Background

This study aimed to explore the process, clinical, and patient-reported outcomes of older adults who received an interdisciplinary Comprehensive Geriatric Assessment (CGA) in the emergency department (ED) over a six-month period after their initial ED attendance.

Patients and Methods

A prospective cohort study recruited older adults aged ≥65 years who presented to the ED of a university teaching hospital in Ireland. Baseline assessment data comprising a battery of demographic variables and validated indices were obtained at the index ED attendance. Telephone interviews were completed with participants at 30- and 180-day follow-up. The primary outcome was incidence of hospital admission following the index ED attendance. Secondary outcomes included participant satisfaction, incidence of functional decline, health-related quality of life, incidence of unscheduled ED re-attendance(s), hospital (re)admission(s), nursing home admission, and death.

Results

A total of 133 participants (mean age 82.43 years, standard deviation = 6.89 years; 71.4% female) were recruited; 21.8% of the cohort were admitted to hospital following the index ED attendance with a significant decline in function reported at hospital discharge (Z = 2.97, p = 0.003). Incidence of 30- and 180-day unscheduled ED re-attendance was 10.5% and 24.8%, respectively. The outcome at the index ED attendance was a significant predictor of adverse outcomes whereby those who were discharged home had significantly lower odds of multiple adverse process outcomes at 30- and 180-day follow-up, and significantly higher function and health-related quality of life at 30-day follow-up.

Conclusion

While this study was observational in nature, findings suggest CGA in the ED may improve outcomes by mitigating against the adverse effects of potentially avoidable hospital admissions and focusing on a longitudinal approach to healthcare delivery at the primary-secondary care interface. Future research should be underpinned by an experimental study design to address key limitations in this study.

Effectiveness of occupational therapy interventions on function and occupational performance among adults with conditions of the hand, wrist, and forearm: A systematic review and meta-analysis

INTRODUCTION

This systematic review and meta-analysis examines the effectiveness of occupational therapy interventions for adults with conservatively managed conditions of the hand, wrist, and forearm.

METHODS

Searches were carried out in CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, MEDLINE (OVID), EMBASE, and PubMed. Grey literature was searched for via Google Scholar. A systematic literature search was undertaken for randomised studies that examined occupational therapy interventions for treatment of hand, wrist, and forearm conditions. The primary outcome was function, with secondary outcomes of occupational performance, satisfaction with occupational performance, pain, and quality of life. Meta-analyses were completed, and GRADE was used to determine the certainty of evidence.

RESULTS

Twelve studies with 1429 participants were identified. Interventions included combinations of occupation-based intervention, assistive device provision, education, orthosis provision, and exercise programmes for arthritis, carpal tunnel syndrome, and fracture and tendon injuries of the hand, wrist, and forearm. Occupational therapy resulted in an improvement of function (REM, SMD -0.27, 95% CI -0.00 to -0.53, I2  = 69%, low certainty evidence) (p = 0.05), occupational performance (REM, SMD 0.83, 95% CI 1.61-0.06, I2  = 91%, low certainty evidence) (p = 0.04), satisfaction with occupational performance (REM, SMD 0.74, 95% CI 1.42-0.05, I2  = 89%, low certainty evidence) (p = 0.03), and pain reduction (FEM, MD -1.35, 95% CI -0.84 to -1.86, I2  = 0%, moderate certainty evidence) (p < 0.00001).

CONCLUSION

Further high-quality research is recommended to determine the effects of occupational therapy interventions on specific upper limb conditions, inclusive of a broader range of clinical and patient reported outcome measures.

Exploring the Impact of COVID-19 on Home Care Workers: A Qualitative Study

This qualitative study aimed to gain insight into the impact of COVID-19 on Home Care Workers (HCWs). During COVID-19 HCWs provided a lifeline for home care clients to support older people remaining living in their own homes. With a high-risk client base, HCWs were one of the few (Health and Social Care Professional) HSCPs to continue providing home-based care throughout COVID-19. Despite these contributions HCWs provided for aging in place during COVID-19, a paucity of research exists in relation to the challenges and impact of the pandemic on HCWs. Three in-person focus groups were conducted (n = 23). Two main themes were produced guided by a Reflexive Thematic Analysis approach to enable the researchers to best represent the participants experiences: Challenges and concerns to the personal and private lives of HCWs and Navigating home-based complexities of HCWs workplace during COVID-19. health care challenges to minimize impact to HCWs issues to create a safe workplace for HCWs.

Exploring stakeholders' experiences of comprehensive geriatric assessment in the community and out-patient settings: a qualitative evidence synthesis

BACKGROUND

Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary process that addresses an older adult's biopsychosocial capabilities to create an integrated and co-ordinated plan of care. While quantitative evidence that demonstrates the positive impacts of CGA on clinical and process outcomes has been synthesised, to date qualitative research reporting how older adults and service providers experience CGA has not been synthesised. This study aimed to systematically review and synthesise qualitative studies reporting community-dwelling older adults', caregivers' and healthcare professionals' (HCP) experiences of CGA in the primary care and out-patient (OPD) setting.

METHOD

We systematically searched five electronic databases including MEDLINE, CINAHL, PsycINFO, PsycARTICLES and Social Sciences Full Text targeting qualitative or mixed methods studies that reported qualitative findings on older adults', caregivers' and HCPs' experiences of CGA in primary care or out-patient settings. There were no language or date restrictions applied to the search. The protocol was registered with the PROSPERO database (Registration: CRD42021283167). The methodological quality of the included studies was appraised using the Critical Appraisal Skills Programme checklist for qualitative research. Results were synthesised according to Noblit and Hare's seven-step approach to meta-ethnography, which involves an iterative and inductive process of data synthesis.

RESULTS

Fourteen studies were included where CGA was completed in the home, general practice, out-patient setting in acute hospitals and in hybrid models across the community and hospital-based OPD settings. Synthesis generated four key themes: (1) CGA is experienced as a holistic process, (2) The home environment enhances CGA, (3) CGA in the community is enabled by a collaborative approach to care, and (4) Divergent experiences of the meaningful involvement of older adults, caregivers and family in the CGA process.

CONCLUSION

Findings demonstrate that CGA in a home-based or OPD setting allows for a holistic and integrated approach to care for community-dwelling older adults while increasing patient satisfaction and accessibility of healthcare. Healthcare professionals in the community should ensure meaningful involvement of older adults and their families or caregivers in the CGA process. Further robustly designed and well reported trials of different models of community-based CGA informed by the findings of this synthesis are warranted.

Stakeholders' experiences of comprehensive geriatric assessment in an inpatient hospital setting: a qualitative systematic review and meta-ethnography

BACKGROUND

Comprehensive geriatric assessment (CGA) is considered the gold standard approach to improving a range of outcomes for older adults living with frailty admitted to hospital. To date, research has predominantly focused on quantitative syntheses of the international evidence with limited focus on qualitative synthesis of stakeholder perspectives. This review aims to resolve this research gap by identifying and synthesising qualitative studies reporting multiple stakeholders' experiences of inpatient CGA.

METHODS

A systematic search of five electronic databases was conducted. Qualitative or mixed methods studies that included qualitative findings on the experiences of CGA in an inpatient hospital setting from the perspective of healthcare professionals (HCP), older adults, and those important to them were included. The protocol was registered on PROSPERO (Registration: CRD42021283167) and the 10-item Critical Appraisal Skills Programme checklist was used to appraise the methodological quality of included studies. Results were synthesised as a meta-ethnography.

RESULTS

Eleven studies, which reported on the experiences of 153 HCPs, 91 older adults and 57 caregivers were included. The studies dated from 2011 to 2021 and three key themes were identified: (1) HCPs, older adults and caregivers report conflicting views on CGA as a holistic process, (2) most HCPs, but only some older adults and caregivers view CGA goalsetting and care planning as collaborative, and (3) all stakeholders value care continuity during the transition from hospital to home but often fail to achieve it.

CONCLUSION

While HCPs, older adults, and caregivers' values and ambitions related to CGA broadly align, their experiences often differ. The identified themes highlight organisational and relational factors, which positively and negatively influence CGA practices and processes in an inpatient hospital setting.

Effectiveness of occupational therapy-led computer-aided interventions on function among adults with conditions of the hand, wrist, and forearm: A systematic literature review and meta-analysis

Introduction

Upper extremity injuries are common, and often treated by occupational therapists. The need to evaluate the effectiveness of occupational therapy interventions to guide practice is pertinent. This systematic review and meta-analysis investigate the effectiveness of occupational therapy-led computer-aided interventions among adults with conditions of the hand, wrist, and forearm.

Methods

A systematic literature search of five databases was undertaken for randomized studies examining occupational therapy-led computer-aided interventions for the treatment of hand, wrist, and forearm conditions. The primary outcome was function, with secondary outcomes of pain, grip and pinch strength. The quality of the included studies was independently assessed using the Cochrane Risk of Bias V2 tool. Meta-analyses were completed.

Results

Three randomized controlled trials were included with 176 participants. One study reported on app use on a tablet and two studies reported on computer gaming. Participants had a variety of hand and wrist diagnoses, treated both conservatively and operatively. There is limited evidence demonstrating that computer-based interventions are as effective as other occupational therapy-led interventions in improving function, pain, grip and pinch strength post-intervention, including small effect size following meta-analysis: grip strength (Fixed Effects Model, SMD 0.13, 95% CI 2.63; -2.36, I2 = 0%) and pinch strength (Fixed Effects Model, SMD -0.12, 95% CI 1.25; -1.50, I2 = 11%).

Conclusions

Limited evidence was found to support the use of computer-aided interventions for adults with a hand, wrist or forearm injury. Further high-quality research is recommended inclusive of a broader range of technologies and a broader range of clinical and patient-reported outcome measures.

Comprehensive geriatric assessment-where are we now, where do we need to be in the context of global ageing?

Comprehensive geriatric assessment (CGA) is the cornerstone of modern geriatric medicine and the framework around which conventional and new models of care for older people are developed. Whilst there are a substantial number of reviews synthesising the evidence on patient and service outcomes from CGA, as an intervention it remains poorly described. There is a lack of detail on how a CGA plan is coordinated, delivered and followed up, especially outside of acute care. This commentary reflects on the authors' experience of extracting data from 57 published studies on CGA. CGA as an intervention is akin to a 'black box' in terms of describing and measuring participants' interactions with CGA activity in terms of time, frequency and amount (dose) received. There is also a lack of detail on how newly established CGA teams become effective, interdisciplinary, high functioning and sustainable teams. The CGA knowledge-do gap persists with a need to draw from complex system theory and implementation science frameworks to better describe the intervention and understand the influence of the organisation and health service within which CGA is operationalised. Equally, the voice of older people, families and staff is critical in the conduct and evaluation of CGA, and how it evolves as a model to meet the growing needs of ageing populations.

A Physiotherapy-Led Transition to Home Intervention for Older Adults Following Emergency Department Discharge: A Pilot Feasibility Randomised Controlled Trial (ED PLUS)

Background

Older adults frequently attend the emergency department (ED) and experience high rates of subsequent adverse outcomes including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. Our aim was to evaluate the feasibility of a physiotherapy-led integrated care intervention for older adults discharged from the ED (ED PLUS).

Patients and Methods

Older adults presenting to the ED of a university teaching hospital with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED PLUS. ED PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient's home. Feasibility and acceptability were assessed quantitatively and qualitatively. All clinical and process outcomes were assessed by a research nurse blinded to group allocation. Data analyses were primarily descriptive.

Results

Twenty-nine participants were recruited indicating a 67% recruitment rate. At 6 months, there was 100% retention in the usual care group, 88% in the CGA group and 90% in the ED PLUS group. ED PLUS participants expressed positive feedback, and there was a trend towards improved function and quality of life and less ED revisits and unscheduled hospitalisations in the ED PLUS group.

Conclusion

ED PLUS bridges the transition of care between the index visit to the ED and the community and is feasible using systematic recruitment strategies. Despite recruitment challenges in the context of COVID-19, the intervention was successfully delivered and well received by participants. There was a lower incidence of functional decline and improved quality of life in the ED PLUS group.

Trial Registration

The trial was registered in Clinical Trials Protocols and Results System as of 21st July 2021, with registration number NCT04983602.

Establishing the core elements of a frailty at the front door model of care using a modified real-time Delphi technique

BACKGROUND

Innovations in models of care for older adults living with frailty presenting to the emergency department (ED) have become a key priority for clinicians, researchers and policymakers due to the deleterious outcomes older adults experience due to prolonged exposure to such an environment. This study aimed to develop a set of expert consensus-based statements underpinning operational design, outcome measurement and evaluation of a Frailty at the Front Door (FFD) model of care for older adults within an Irish context.

METHODS

A modified real-time Delphi method was used. Facilitation of World Café focus groups with an expert panel of 86 members and seperate advisory groups with a Public and Patient Involvement panel of older adults and members of the Irish Association of Emergency Medicine generated a series of statements on the core elements of the FFD model of care. Statements were analysed thematically and incorporated into a real-time Delphi survey, which was emailed to members of the expert panel. Members were asked to rank 70 statements across nine domains using a 9-point Likert scale. Consensus criteria were defined a priori and guided by previous research using 9-point rating scales.

RESULTS

Fifty members responded to the survey representing an overall response rate of 58%. Following analyses of the survey responses, the research team reviewed statements for content overlap and refined a final list of statements across the following domains: aims and objectives of the FFD model of care; target population; screening and assessment; interventions; technology; integration of care; evaluation and metrics; and research.

CONCLUSION

Development of a consensus derived FFD model of care represents an important step in generating national standards, implementation of a service model as intended and enhances opportunities for scientific impact. Future research should focus on the development of a core outcome set for studies involving older adults in the ED.

OptiCogs: feasibility of a multicomponent intervention to rehabilitate people with cognitive impairment post-stroke

BACKGROUND

Stroke is a leading cause of death and disability worldwide. Despite the prevalence and associated burden of cognitive impairment post-stroke, there is uncertainty regarding optimal cognitive rehabilitation for people post-stroke. This study aimed to assess whether a multicomponent intervention, called OptiCogs, is feasible, acceptable, and safe for people with cognitive impairment post-stroke. A secondary aim was to explore changes in cognitive function, fatigue, quality of life, physical function, and occupational performance, from pre-intervention to post-intervention.

METHODS

A feasibility study was conducted where people post-stroke with cognitive impairment enrolled in a 6-week multicomponent intervention. The primary outcomes recorded included response rate, recruitment rate, retention rate, adherence to the intervention protocol, adverse events, and acceptability of the intervention to people post-stroke. Secondary outcomes included (i) change in cognitive functioning using the Addenbrooke's Cognitive Examination III, (ii) fatigue using the Fatigue Severity scale, (iii) quality of life using the Stroke Specific Quality of Life scale (iv) physical function using the patient-reported outcomes measurement information system, and (v) patient-reported occupational performance using the Canadian Occupational Performance Measure. The Consolidated Standards of Reporting Trials extension reporting guidelines were followed, for pilot and feasibility studies, to standardize the conduct and reporting of this study.

RESULTS

The response rate was 10.9%. Nine eligible participants were enrolled during the 4-month recruitment period, with eight participants completing the entire 6-week intervention, as well as the pre- and post-intervention outcome measures. There were no reported adverse events. Participants were satisfied with the intervention and found it acceptable overall. Results of the secondary outcomes were promising for cognitive function (ACE III, pre: 63.3 ± 23.9 to post: 69 ± 24.6), fatigue (FSS, pre: 52.5 ± 7.3 to post: 45.6 ± 7.2), quality of life (SSQoL, pre: 131.0 ± 26.3 to post: 169.9 ± 15.3), physical function (PROMIS-PF, pre: 15.5 ± 6.3 to post: 15.8 ± 5.3), and occupational performance (COPM performance, pre: 9.3 ± 2.3 to post: 22.9 ± 4.2) and COPM satisfaction, pre: 9.9 ± 2.1 to post: 22.7 ± 3.5).

CONCLUSION

Preliminary results suggest low-modest recruitment and high retention rates for the OptiCogs intervention. Changes in cognitive function, fatigue, quality of life, and self-reported occupational performance show improvement from pre- to post-intervention. These potential benefits require further testing in a larger pilot trial.

TRIAL REGISTRATION

NCT05414539.

A qualitative evidence synthesis (QES) exploring the barriers and facilitators to screening in emergency departments using the theoretical domains framework

BACKGROUND

Validated screening tools can be utilised to detect early disease processes and risk factors for disease and adverse outcomes. Consequently, identifying individuals in need of early intervention and targeted assessment can be achieved through the implementation of screening in the ED. Successful implementation can be impacted by a lack of resources and ineffective integration of screening into the clinical workflow. Tailored implementation processes and staff training, which are contextually specific to the ED setting, are facilitators to effective implementation. This review will assist in the identification of barriers and facilitators to screening in the ED using a QES to underpin implementation processes. Healthcare workers engage in screening in the ED routinely. Consequently, this review focused on synthesizing the experience of healthcare workers (HCWs) who are involved in this process. This synthesis is informed by a QES protocol published by the lead author in 2021 (Barry et al., HRB Open Res 3:50, 2021).

METHODOLOGY

A comprehensive literature search, inclusive of grey literature sources, was undertaken. Initially, an a priori framework of themes was formed to facilitate the interpretation and organisation of search results. A context specific conceptual model was then formulated using "Best fit" framework synthesis which further assisted in the interpretation of data that was extracted from relevant studies. Dual blind screening of search results was undertaken using RAYYAN as a platform. Thirty studies were identified that met the inclusion criteria. Dual appraisal of full text articles was undertaken using CASP, GRADE CERQual assessed confidence of findings and data extraction was performed by two reviewers collaboratively.

FINDINGS

This is the first known synthesis of qualitative research on HCW's experiences of screening in the ED. Predominantly, the findings illustrate that staff experience screening in the ED as a complex challenging process. The barriers and facilitators identified can be broadly categorised under preconditions to screen, motivations to screen and knowledge and skills to screen. Competing interests in the ED, environmental stressors such as overcrowding and an organisational culture that resists screening were clear barriers. Adequate resources and tailored education to underpin the screening process were clear facilitators.

TRIAL REGISTRATION

PROSPERO: CRD42020188712 05/07/20.

Clinical research stakeholders' experiences of clinical research during COVID-19: a qualitative study

BACKGROUND

The COVID-19 pandemic created a complex high-risk clinical research environment with clinical research activities significantly impacted. Clinical research stakeholders adapted rapidly to new clinical practices; PPE, infection control policies, all while engaging with a more unwell patient demographic. The aim of this study is to explore the experiences of conducting clinical research during COVID-19 with clinical research stakeholders.

METHODS

This qualitative study of semi-structured interviews conducted with clinical research stakeholders in an acute Hospital setting across a variety of disciplines; Consultant Geriatrician, Clinical Research Nurse, Occupational Therapy, Physiotherapy. Interviews were fully transcribed prior to reflexive thematic analysis. NVivo software was used to support data management and analysis.

RESULTS

Three main themes were produced; (1) The challenging COVID-19 clinical research landscape, (2) COVID-19 clinical research communication barriers, and (3) Adaptations and learnings from clinical research during COVID-19.

CONCLUSIONS

This study explored the experiences of conducting clinical research during COVID-19 with clinical research stakeholders examining challenges faced and adaptations required. The findings inform, equip and support clinical research stakeholders in the event of future adverse public health events.

A qualitative study examining young peoples' perceptions and adherence to COVID-19 public health guidelines in Ireland

BACKGROUND

Public health measures are the main intervention to stop the spread of COVID-19. They rely on the adherence to everyday health behaviors, and depend on those at high and low personal risk of serious disease to comply. Young people are crucial to stemming community transmission, and are often living in shared housing and at a stage of their lives with more economic uncertainty than older groups. Public health messaging has relied on the mantra that we are 'in it together,' despite very diverse experiences of the pandemic across different groups. The central aim of this research is to understand and optimize young peoples' engagement with public health guidelines with the view to improve future adherence with public health initiatives.

METHOD

Twelve young people were interviewed as part of this research, ranging from 18 to 24 years. Interviewees were chosen to ensure that there was a diverse range of opinions within the participant pool. Interviews were semi-structured with open questions and the flexibility to explore the topics of interest that arose. All interviews were fully transcribed and analyzed using thematic analysis.

RESULTS

This study found that participants deemed the consequences of lockdown a greater threat than infection with SARS-COV-2. Participants expressed concerns about the government's handling of the pandemic. Some felt young peoples' interests were not represented by authorities. There were concerns that messaging was inaccurate, difficult to understand, and filled with statistical and medical jargon. These perceptions underpinned a sense that the guidelines could be broken in good conscience as well as result in accidental breaches of the guidelines. Though wider community factors were often cited as having a positive influence on health behavior, differences and division were seen to inspire trust or adherence.

CONCLUSION

These findings provide an insight into the psychological, financial and physical difficulties young people face as a consequence of pandemic public health measures and lockdowns in particular. They highlight the need for better communication with young people to support and embed trust in authorities and the scientific and political community.

Clinician consensus on "Inappropriate" presentations to the Emergency Department in the Better Data, Better Planning (BDBP) census: a cross-sectional multi-centre study of emergency department utilisation in Ireland

BACKGROUND

Utilisation of the Emergency Department (ED) for non-urgent care increases demand for services, therefore reducing inappropriate or avoidable attendances is an important area for intervention in prevention of ED crowding. This study aims to develop a consensus between clinicians across care settings about the "appropriateness" of attendances to the ED in Ireland.

METHODS

The Better Data, Better Planning study was a multi-centre, cross-sectional study investigating factors influencing ED utilisation in Ireland. Data was compiled in patient summary files which were assessed for measures of appropriateness by an academic General Practitioner (GP) and academic Emergency Medicine Consultant (EMC) National Panel. In cases where consensus was not reached charts were assessed by an Independent Review Panel (IRP). At each site all files were autonomously assessed by local GP-EMC panels.

RESULTS

The National Panel determined that 11% (GP) to 38% (EMC) of n = 306 lower acuity presentations could be treated by a GP within 24-48 h (k = 0.259; p < 0.001) and that 18% (GP) to 35% (EMC) of attendances could be considered "inappropriate" (k = 0.341; p < 0.001). For attendances deemed "appropriate" the admission rate was 47% compared to 0% for "inappropriate" attendees. There was no consensus on 45% of charts (n = 136). Subset analysis by the IRP determined that consensus for appropriate attendances ranged from 0 to 59% and for inappropriate attendances ranged from 0 to 29%. For the Local Panel review (n = 306) consensus on appropriateness ranged from 40 to 76% across ED sites.

CONCLUSIONS

Multidisciplinary clinicians agree that "inappropriate" use of the ED in Ireland is an issue. However, obtaining consensus on appropriateness of attendance is challenging and there was a significant cohort of complex heterogenous presentations where agreement could not be reached by clinicians in this study. This research again demonstrates the complexity of ED crowding, the introduction of evidence-based care pathways targeting avoidable presentations may serve to alleviate the problem in our EDs.

Clinical Frailty Scale as a predictor of adverse outcomes following aortic valve replacement: a systematic review and meta-analysis

OBJECTIVES

Assessment of frailty prior to aortic valve intervention is recommended in European and North American valvular heart disease guidelines. However, there is a lack of consensus on how it is best measured. The Clinical Frailty Scale (CFS) is a well-validated measure of frailty that is relatively quick to calculate. This meta-analysis sought to examine whether the CFS predicts mortality and morbidity following either transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR).

METHODS

Nine electronic databases were searched systematically for data on clinical outcomes post-TAVI/SAVR, where patients had undergone preoperative frailty assessment using the CFS. The primary endpoint was 12-month mortality. TAVI and SAVR data were assessed and reported separately. For each individual study, the incidence of adverse outcomes was extracted according to a CFS score of 5-9 (ie, frail) versus 1-4 (ie, non-frail), with meta-analysis performed using a random effects model.

RESULTS

Of 2612 records screened, nine were included in the review (five TAVI, three SAVR and one which included both interventions). Among 4923 TAVI patients, meta-analysis showed 12-month mortality rates of 19.1% for the frail cohort versus 9.8% for the non-frail cohort (RR 2.53 (1.63 to 3.95), p<0.001, I2=83%). For the smaller cohort of SAVR patients (n=454), mortality rates were 20.3% versus 3.9% for the frail and non-frail cohorts, respectively (RR 5.08 (2.31 to 11.15), p<0.001, I2=5%).

CONCLUSIONS

Frailty, as determined by the CFS, was associated with an increased mortality risk in the 12 months following either TAVI or SAVR. These data would support its use in the preoperative assessment of elderly patients undergoing aortic valve interventions.

Impact of serum sodium concentrations, and effect modifiers on mortality in the Irish Health System

BACKGROUND

Abnormalities of serum sodium are associated with increased mortality risk in hospitalised patients, but it is unclear whether, and to what extent other factors influence this relationship. We investigated the impact of dysnatraemia on total and cause-specific mortality in the Irish health system while exploring the concurrent impact of age, kidney function and designated clinical work-based settings.

METHODS

A retrospective cohort study of 32,666 participants was conducted using data from the National Kidney Disease Surveillance System. Hyponatraemia was defined as < 135 mmol/L and hypernatraemia as > 145 mmol/L with normal range 135-145 mmol/L. Multivariable Cox proportional hazards regression was used to estimate hazard ratios (HR's) and 95% Confidence Intervals (CIs) while penalised spline models further examined patterns of risk.

RESULTS

There were 5,114 deaths (15.7%) over a median follow up of 5.5 years. Dysnatraemia was present in 8.5% of patients overall. In multivariable analysis, both baseline and time-dependent serum sodium concentrations exhibited a U-shaped association with mortality. Hyponatremia was significantly associated with increased risk for cardiovascular [HR 1.38 (1.18-1.61)], malignant [HR: 2.49 (2.23-2.78)] and non-cardiovascular/non-malignant causes of death [1.36 (1.17-1.58)], while hypernatremia was significantly associated with cardiovascular [HR: 2.16 (1.58-2.96)] and non-cardiovascular/ non-malignant deaths respectively [HR: 3.60 (2.87-4.52)]. The sodium-mortality relationship was significantly influenced by age, level of kidney function and the clinical setting at baseline (P < 0.001). For hyponatraemia, relative mortality risks were significantly higher for younger patients (interaction term P < 0.001), for patients with better kidney function, and for patients attending general practice [HR 2.70 (2.15-3.36)] than other clinical settings. For hypernatraemia, age and kidney function remained significant effect modifiers, with patients attending outpatient departments experiencing the greatest risk [HR 9.84 (4.88-18.62)] than patients who attended other clinical locations. Optimal serum sodium thresholds for mortality varied by level of kidney function with a flattening of mortality curve observed for patients with poorer kidney function.

CONCLUSION

Serum sodium concentrations outside the standard normal range adversly impact mortality and are associated with specific causes of death. The thresholds at which these risks appear to vary by age, level of kidney function, and are modified in specific clinical settings within the health system.

Screening instruments to predict adverse outcomes for undifferentiated older adults attending the Emergency Department: Results of SOAED prospective cohort study

BACKGROUND

frailty screening facilitates the stratification of older adults at most risk of adverse events for urgent assessment and subsequent intervention. We assessed the validity of the Identification of Seniors at Risk (ISAR), Clinical Frailty Scale (CFS), Programme on Research for Integrating Services for the Maintenance of Autonomy seven item questionnaire (PRISMA-7) and InterRAI-ED at predicting adverse outcomes at 30 days and 6 months amongst older adults presenting to the Emergency Department (ED).

METHODS

a prospective cohort study of adults ≥65 years who presented to the ED was conducted. The ISAR, CFS, PRISMA-7 and InterRAI-ED were assessed. Blinded follow-up telephone interviews were completed at 30 days and 6 months to assess the incidence of mortality, ED re-attendance, hospital readmission, functional decline and nursing home admission. The sensitivity, specificity, negative predictive value and positive predictive value of the screening tools were calculated using 2 × 2 tables.

RESULTS

a total of 419 patients were recruited; 47% female with a mean age of 76.9 (Standard deviation = 7.2). The prevalence of frailty varied across the tools (CFS 57% versus InterRAI-ED 70%). At 30 days, the mortality rate was 5.1%, ED re-attendance 18.1%, hospital readmission 14%, functional decline 47.6% and nursing home admission 7.1%. All tools had a high sensitivity and positive predictive value for predicting adverse outcomes.

CONCLUSION

older adults who screened positive for frailty were at significantly increased risk of experiencing an adverse outcome at 30 days with the ISAR being the most sensitive tool. We would recommend the implementation of the ISAR in the ED setting to support clinicians in identifying older adults most likely to benefit from specialised geriatric assessment and intervention.

Multidisciplinary inpatient rehabilitation for older adults with COVID-19: a systematic review and meta-analysis of clinical and process outcomes

BACKGROUND

Older adults are at increased risk for disease severity and poorer prognosis following COVID-19 infection. The aim of this systematic review and meta-analysis is to explore the impact of multidisciplinary rehabilitation in the acute or post-acute hospital setting for older adults with COVID-19.

METHODS

The Cochrane library, EMBASE, Cinahl and Medline (via EBSCO), PubMed, and Web of Science were systematically searched in June 2022 and a repeat search was completed in March 2023. Screening, data extraction and quality appraisal were conducted independently by two reviewers. Studies reporting outcomes for older adults following multidisciplinary rehabilitation (provided by two or more Health and Social Care Professionals) were included. Both observational and experimental study designs were included. The primary outcome was functional ability. Secondary outcomes included discharge disposition, acute hospital and rehabilitation unit length of stay, mortality, primary and secondary healthcare utilisation, and long-term effects of COVID-19.

RESULTS

Twelve studies met the inclusion criteria, comprising a total of 570 older adults. Where reported, older adults stayed in the acute hospital for a mean of 18 days (95%CI, 13.35- 23.13 days) and in rehabilitation units for 19 days (95%CI, 15.88-21.79 days). There was a significant improvement in functional ability among older adults with COVID-19 who received multidisciplinary rehabilitation (REM, SMD = 1.46, 95% CI 0.94 to 1.98). The proportion of older adults who were discharged directly home following rehabilitation ranged from 62 to 97%. Two studies reported a 2% inpatient mortality rate of older persons during rehabilitative care. No study followed up patients after the point of discharge and no study reported on long term effects of COVID-19.

CONCLUSIONS

Multidisciplinary rehabilitation may result in improved functional outcomes on discharge from rehabilitation units/centres for older adults with COVID-19. Findings also highlight the need for further research into the long-term effect of rehabilitation for older adults following COVID-19. Future research should comprehensively describe multidisciplinary rehabilitation in terms of disciplines involved and the intervention provided.

A qualitative evidence synthesis exploring people after stroke, family members, carers and healthcare professionals' experiences of early supported discharge (ESD) after stroke

OBJECTIVE

Early supported discharge (ESD) after stroke has been shown to generate significant cost savings and reduce both hospital length of stay, and long-term dependency. This study aimed to systematically review and synthesise qualitative studies of the experiences and views of ESD from the perspective of people after stroke, their family members, carers and healthcare professionals.

METHOD

A systematic search of eleven databases; CINAHL, PubMed Central, Embase, MEDLINE, PsycINFO, Sage, Academic Search Complete, Directory of Open Access Journal, The Cochrane Library, PsycARTICLES and SCOPUS, was conducted from 1995 to January 2022. Qualitative or mixed methods studies that included qualitative findings on the perspectives or experiences of people after stroke, family members, carers and healthcare professionals of an ESD service were included. The protocol was registered with the Prospero database (Registration: CRD42020135197). The methodological quality of studies was assessed using the 10-item CASP checklist for qualitative studies. Results were synthesised using Thomas and Harden's three step approach for thematic synthesis.

RESULTS

Fourteen studies were included and five key themes were identified (1) ESD eases the transition home, but not to community services, (2) the home environment enhances rehabilitation, (3) organisational, and interprofessional factors are critical to the success of ESD, (4) ESD is experienced as a goal-focused and collaborative process, and (5) unmet needs persisted despite ESD.

CONCLUSION

The findings of this qualitative evidence synthesis highlight that experiences of ESD were largely very positive. The transition from ESD to community services was deemed to be problematic and other unmet needs such as information needs, and carer support require further investigation.

1298 THE IMPACT OF ACUTE HEALTHCARE UTILISATION ON FUNCTIONAL DECLINE IN OLDER ADULTS OVER TIME: A POPULATION-BASED COHORT STUDY

Introduction

Acute healthcare use varies by age, with older adults the highest users of most acute healthcare services. International reports have highlighted increased use of Emergency Department (ED) services by older adults. Older adults who visit the ED may be admitted to hospital or discharged home and are vulnerable to adverse outcomes including cognitive decline, falls, readmission, mortality and hospital acquired limitations in activities of daily living. Using data from The Irish Longitudinal Study on Ageing (TILDA), the aim of this study was to investigate the impact of acute healthcare utilisation at baseline on subjective and objective measures of function at four-year follow-up in older adults.

Methods

This study represents a secondary analysis of a prospective cohort study where data from Wave 1 (baseline) and Wave 3 (four-year follow up) of TILDA were analysed in conjunction with a public and patient involvement group of older adults. Acute healthcare utilisation was defined as an ED visit with or without hospitalisation in the previous 12 months. Function was assessed objectively using Timed-Up-and Go (TUG) and grip strength and subjectively using self-report limitations in activities of daily living and instrumental activities of daily living.

Results

A total of 1516 participants met the study inclusion criteria. Mean age was 70.9 years (SD=4.6) and 48% were male. At baseline, 1280 participants reported no acute healthcare use. 118 indicated an ED visit but no hospitalisation in the previous twelve months and 118 reported both an ED visit and hospitalisation. Adjusting for all covariates, compared to those with no acute healthcare utilisation, those with an ED visit with no hospital admission had poorer TUG performance at follow up (β= 0.67, 95% CI: 0.34, 1.29, p=0.039).

Conclusion

The results of this study support a relationship between acute healthcare utilisation and functional decline assessed by TUG at follow-up.

A physiotherapy-led transition to home intervention for older adults following Emergency Department discharge: a pilot feasibility randomised controlled trial

INTRODUCTION

Older adults frequently attend the emergency department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. Our aim was to evaluate the feasibility of a physiotherapy-led integrated care intervention for older adults discharged from the ED (ED-PLUS).

METHODS

Older adults presenting to the ED with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED-PLUS (trial registration: NCT04983602). ED-PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a 6-week, multi-component, self-management programme in the patient's own home. Feasibility (recruitment and retention rates) and acceptability of the programme were assessed quantitatively and qualitatively. Functional decline was examined post-intervention using the Barthel Index. All outcomes were assessed by a research nurse blinded to group allocation.

RESULTS

Twenty-nine participants were recruited, indicating 97% of our recruitment target; 90% of participants completed the ED-PLUS intervention. All participants expressed positive feedback about the intervention. The incidence of functional decline at 6 weeks was 10% in the ED-PLUS group versus 70%-89% in the usual care and CGA-only groups.

DISCUSSION

High adherence and retention rates were observed among participants and preliminary findings indicate a lower incidence of functional decline in the ED-PLUS group. Recruitment challenges existed in the context of COVID-19. Data collection is ongoing for 6-month outcomes.

Early supported discharge for older adults admitted to hospital with medical complaints: a systematic review and meta-analysis

INTRODUCTION

Early supported discharge (ESD) aims to link acute and community care, allowing hospital inpatients to return home and continue to receive the necessary input from healthcare professionals that they would otherwise receive in hospital. It has been researched extensively in the stroke population, showing reduced length of stay for patients and improved functional outcomes. This systematic review aims to explore the totality of evidence for the use of ESD in an older adult population who have been hospitalised with medical complaints.

METHODS

Systematic searches were conducted in MEDLINE, CINAHL, Ebsco, Cochrane Library and EMBASE. Randomised controlled trials (RCTs) and quasi-RCTs were included if they provided an ESD intervention to older adults admitted to hospital for medical complaints compared with usual inpatient care. Patient and process outcomes were explored. The Cochrane Risk of Bias Tool was used to assess methodological quality. A meta-analysis was conducted using RevMan 5.4.1.

RESULTS

Five RCTs met the inclusion criteria. The quality of the trials was mixed overall, with high levels of heterogeneity. ESD demonstrated a statistically significant reduction in length of stay (MD -6.04 days, 95% CI -9.76 to -2.32) and improvements in function, cognition, and health-related quality of life, with no increased risk of long-term care admission, hospital re-admission or mortality in the ESD interventions versus usual care groups.

DISCUSSION

This review demonstrates that ESD positively impacts patient and process outcomes for older adults. Further consideration should be given to exploring the experiences of those involved in ESD including older adults, family members/caregivers as well as healthcare professionals.

Are we there yet?' Distance to definitive care for Irish patients in the Better Data, Better Planning (BDBP) study

BACKGROUND

Residing long distances from definitive care compromises patient safety and, in rural Ireland, travel distance to health care can be substantial, particularly in light of national General Practitioner (GP) shortages and hospital reconfigurations. The aim of this research is to describe the profile of patients attending Irish Emergency Departments (EDs) in terms of distance from GP care and definitive care in the ED.

METHOD

The 'Better Data, Better Planning' (BDBP) census was a multi-centre, cross-sectional study of n=5 urban and rural EDs in Ireland throughout 2020. At each site, all adults presenting over a 24-h census period were eligible for inclusion. Data were collected on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED, with analysis in SPSS.

RESULTS

For n=306 participants, median distance to a GP was 3 km (range 1-100 km) and median distance to the ED was 15 km (range 1-160km). Most participants (n=167, 58%) lived within 5 km of their GP and within 10 km of the ED (n=114, 38%). However, 8% of patients lived ≥15 km from their GP and 9% of patients lived &#8805;50 km from their nearest ED. Patients living >50 km from the ED were more likely to be transported by Ambulance (p<0.05).

CONCLUSIONS

Proximity to health services, by geographical location, is poorer in rural regions, so it's important that these patients have equity of access to definitive care. Therefore, expansion of alternative care pathways in the community and additional resourcing of the National Ambulance Service with enhanced aeromedical support is essential in the future.

Early Supported Discharge for Older Adults Admitted to Hospital with Medical Complaints: A Qualitative Study Exploring the Views of Stakeholders

Introduction

Early supported discharge (ESD) is well established as a model of health service delivery for people with stroke. Emerging evidence indicates that ESD also reduces the length of stay for older medical inpatients. There is a dearth of evidence exploring the views of stakeholders on ESD as a model of care for older medical inpatients. The overall aim of this study is to explore the views and perceptions of older adults, family carers and healthcare professionals on the potential role of ESD for older adults admitted to hospital with medical complaints.

Methods

Purposeful sampling was used to recruit older adults and family carers for interview. For Healthcare Professionals (HCPs), snowball purposeful sampling was used. Phone interviews took place following a semi-structured interview guide. Focus groups were moderated by A-MM. Braun and Clarke's approach to thematic analysis was used. Ethical approval was granted by the HSE Mid-Western Area Regional Ethics Committee in November 2021 (REC Ref. 096/2021).

Results

Fifteen HCPs took part across three focus groups, with six older adults and two family members participating in one-to-one interviews. Three themes were identified: 1. Pre-ESD experiences of providing and receiving older adult inpatient care, 2. Navigating discharge procedures from acute hospital services, 3. A vision for more integrated model of care and a medical ESD team.

Discussion

This study provided insight into the current discharge experiences of older adult care in the acute setting, the potential role for ESD in this population and the key factors that would need to be considered for the running of an ESD service for older adults admitted to hospital with medical complaints.

Conclusion

This research highlights the barriers and facilitators to ESD for older medical inpatients from the perspectives of key stakeholders. Given the adverse outcomes associated with prolonged hospital stay, these findings will help inform the development of a feasibility trial, examining patient and process outcomes for older adults admitted to hospital with medical complaints who receive an ESD intervention.

Development and feasibility of an inter-agency physical activity and education programme for adults with multimorbidity in primary care: Activ8

Background

While physical activity is widely recommended for many long-term conditions, it may be difficult to achieve for patients managing multiple conditions. We aimed to determine the feasibility of an inter-agency exercise and education programme for patients with multimorbidity in primary care.

Methods

We conducted an uncontrolled pilot study with adults with multimorbidity, recruited in two community healthcare organisations in an urban area in Ireland. The six-week pilot intervention combined an individually tailored gym-based exercise programme and education to support self-management. Feasibility of the Activ8 programme was assessed using a mixed methods process evaluation. Outcome measures at baseline and at 6 weeks included recruitment and retention, gait speed, grip strength, quality of life and self-efficacy. Focus groups and interviews explored participants and facilitators’ perceptions of the programme.

Results

19 participants with ≥2 chronic conditions were recruited over three-weeks with similar attrition at both sites (≤40%). Overall, the results indicate that Activ8 was feasible and acceptable to patients and practitioners. Quantitative outcome measures suggested improvements in most outcomes. Qualitative data analysis indicated that Activ8 addressed an overarching concept of patient-centeredness among participants. Three key themes included perceived personal programme impact, the personalised composition of the programme and the evolving nature of primary care practice.

Conclusion

While further definitive evidence is needed and attrition from the programme needs to be considered, the Activ8 Programme was acceptable to both patients and professionals in two different primary care areas with the potential for positive impacts for adults living with multimorbidity.

Is There Evidence of an Association Between Acute Health Care Utilization and Function in Older Adults Over Time? A Population-Based Cohort Study

Background and Objectives

Acute health care use varies by age, with older adults the highest users of acute health care services. Using data from The Irish Longitudinal Study on Ageing (TILDA), the aim of this study was to investigate the association between acute health care utilization (emergency department [ED] visit with or without hospitalization) at baseline and subjective and objective measures of function measured at 4-year follow-up.

Research Design and Methods

This study represents a secondary analysis of a prospective cohort study, where data from Wave 1 (baseline) and Wave 3 of TILDA were analyzed in conjunction with a public and patient involvement group of older adults. Acute health care utilization was defined as an ED visit with or without hospitalization in the previous 12 months. Function was assessed objectively using the Timed Up and Go (TUG) test and a measure of grip strength, and subjectively using self-report limitations in activities of daily living (ADL) and instrumental ADL (IADL).

Results

A total of 1 516 participants met the study inclusion criteria. Mean age was 70.9 ± 4.6 years and 48% were male. At baseline, 1 280 participants reported no acute health care use. One hundred and eighteen indicated an ED visit but no hospitalization in the previous 12 months and 118 reported both an ED visit and hospitalization. Adjusting for all covariates, compared to those with no acute health care utilization, those with an ED visit with no hospital admission had poorer TUG performance at follow-up (β = 0.67, 95% confidence interval: 0.34, 1.29, p = .039).

Discussion and Implications

This paper supports previous research that acute health care events, specifically ED usage, are associated with reduced function for older adults as assessed by TUG at follow-up. No associations were observed for grip strength, ADL, or IADL. Further research is required in this area, exploring ED visits and the possible benefits of evaluating older adults at this stage.

Effectiveness of community-based multidisciplinary integrated care for older people: a protocol for a systematic review

INTRODUCTION

The increasing number of older adults with multiple complex care needs has placed increased pressure on healthcare systems internationally to reorientate healthcare delivery. For many older adults, their first point of contact with the health service is with their general practitioner (GP) and GP participation with integrated care models is the foundation of a population-based approach. A knowledge gap remains in relation to the effectiveness of GP participation in community-based integrated health and social care approaches for older adults. This systematic review aims to examine the effectiveness of multidisciplinary-integrated care for community-dwelling older adults with GP participation.

METHODS AND ANALYSIS

This systematic review will include randomised controlled trials (RCTs), quasi and cluster RCTs focusing on integrated care interventions for community-dwelling older adults by multidisciplinary teams including health and social care professionals and GPs. The databases PUBMED, EMBASE, CINAHL, Central Register of Controlled Trials in the Cochrane Library and MEDLINE will be searched. The primary outcome measure will be functional status. Secondary outcomes will include: primary healthcare utilisation, secondary healthcare utilisation, participant satisfaction with care, health-related quality of life, nursing home admission and mortality. The methodological quality of the studies will be assessed using the Cochrane Risk of Bias Tool V.2. The elements of care integration will be mapped in the individual studies using the Rainbow Model of Integrated Care taxonomy. A meta-analysis will be completed, depending on the uniformity of the data. Grading of Recommendations, Assessment, Development and Evaluation will be used to assess the certainty of evidence.

ETHICS AND DISSEMINATION

Formal ethical approval is not required as all data included are anonymous secondary data. Scientific outputs will be presented at relevant conferences and in collaboration with our public and patient involvement stakeholder panel of older adults at the Ageing Research Centre at the University of Limerick.

PROSPERO REGISTRATION NUMBER

CRD42022309744.

Exploring the facilitation of meaningful leisure activities in designated centres for older persons (nursing homes) in Ireland: A protocol for content documentary analysis of HIQA inspection reports

Background: Nursing homes (NHs) in Ireland are regulated by the Health Information and Quality Authority (HIQA). Regulations for nursing homes under the Health Act 2007 (as amended) states that registered providers must provide residents with facilities for occupation and recreation, and opportunities to participate in activities in accordance with their interests and capacities (Government of Ireland, 2013 - S.I. No. 415/2013). Despite the proven benefits of engagement in meaningful activities, when an older person enters a NH, they often lose autonomy in occupational roles, and engagement in meaningful activities (Causey-Upton, 2015).  In 2019, HIQA highlighted that there were relatively high levels of non-compliance in the area of residents’ rights (HIQA, 2020). Aim: Given the central role of leisure activities to older adults’ health and well-being, this study aims to understand how NH residents in Ireland were afforded opportunities for meaningful engagement in activities prior to and throughout the COVID-19 pandemic (2019 – 2021). This will be conducted through analysing a sample of publicly available HIQA inspection reports for NHs from 2019 – 2021. Methods: A content documentary analysis will be conducted using a qualitative deductive approach. Purposive sampling will be used to select 21 nursing home reports for the years 2019, 2020 and 2021. The sample will include nursing homes reported to be non-compliant, substantially compliant and compliant in the regulation of residents’ rights. An inspection report for each of these NHs (n=21) for the year 2019, 2020 and 2021 will create a sample of 63 reports for analysis. This sample will capture three time points for the 21 NHs pre-pandemic and throughout the pandemic.

The impact of COVID-19 on an Irish Emergency Department (ED): a cross-sectional study exploring the factors influencing ED utilisation prior to and during the pandemic from the patient perspective

BACKGROUND

The collateral damage of SARS-CoV-2 is a serious concern in the Emergency Medicine (EM) community, specifically in relation to delayed care increasing morbidity and mortality in attendances unrelated to COVID-19. The objectives of this study are to describe the profile of patients attending an Irish ED prior to, and during the pandemic, and to investigate the factors influencing ED utilisation in this cohort.

METHODS

This was a cross-sectional study with recruitment at three time-points prior to the onset of COVID-19 in December 2019 (n = 47) and February 2020 (n = 57) and post-Lockdown 1 in July 2020 (n = 70). At each time-point all adults presenting over a 24 h period were eligible for inclusion. Clinical data were collected via electronic records and a questionnaire provided information on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED. Data analysis was performed in SPSS and included descriptive and inferential statistics.

RESULTS

The demographic and clinical profile of patients across time-points was comparable in terms of age (p = 0.904), gender (p = 0.584) and presenting complaint (p = 0.556). Median length of stay in the ED decreased from 7.25 h (IQR 4.18-11.22) in February to 3.86 h (IQR 0.41-9.14) in July (p ≤ 0.005) and differences were observed in disposition (p ≤ 0.001). COVID-19 influenced decision to attend the ED for 31% of patients with 9% delaying presentation. Post-lockdown, patients were less likely to attend the ED for reassurance (p ≤ 0.005), for a second opinion (p ≤ 0.005) or to see a specialist (p ≤ 0.05).

CONCLUSIONS

Demographic and clinical presentations of ED patients prior to the first COVID-19 lockdown and during the reopening phase were comparable, however, COVID-19 significantly impacted health-seeking behaviour and operational metrics in the ED at this phase of the pandemic. These findings provide useful information for hospitals with regard to pandemic preparedness and also have wider implications for planning of future health service delivery.

309 A FRAILTY CENSUS OF INPATIENTS AGED 65 AND OVER ADMITTED TO A MODEL 4 HOSPITAL

Background

Frailty is a risk factor for in-hospital mortality, long hospital stay and functional decline at discharge. Profiling the prevalence and level of frailty within the acute hospital setting is vital to ensure evidence-based practice and service development within the construct of frailty.

Methods

All patients aged ≥65 years and admitted to a medical or surgical inpatient setting, were screened over a 12-hour period (08:00-20:00) using validated frailty and co-morbidity scales. Age and Gender Demographics, Clinical Frailty Scale (CFS), Charlson Co-morbidity Index (CHI) and admitting specialty (Medical/Surgical) were collected. The data was fully anonymised and ethical approval was granted. Descriptive statistics were used to profile the cohort and Chi-squared tests applied for comparisons.

Results

Within a sample of 413 patients, 291(70%) were ≥65yrs. Of this cohort, 202(70%) were ≥75yrs. 207(71%) utilised in-patient medical services and 121(41%) surgical services while 37(12%) used both. The mean CFS was 6 indicating moderate frailty levels and the mean CCI score was 4 denoting moderate co-morbidity. Overall: 195(67%) had moderate-severe frailty (CSF ≥6) while 218 (75%) had moderate-severe co-morbidity (CCI Mod 3-4, Severe ≥5). Associations with age &gt;75 and frailty (p=0.001) and medical service usage and frailty (p=0.004) were established. No significant differences were observed across genders for CFS (p=0.110) and CCI (p=0.465).

Conclusion

There is a high prevalence of frailty and co-morbidity within the admitted patient cohort ≥65yrs. Overcrowding across the hospital system and higher levels of frailty and comorbidity will contribute to increased lengths of stay and the need for specialist intervention, particularly for those ≥75yrs who represented 70% of patients screened. With an increased focus on the integration of care for older adults across care transitions, there is a clear need for expansion of frailty-based services and staff training in frailty care across the hospital and community setting.

299 OLDER PERSONS’ EXPERIENCES AND PERSPECTIVES OF COMPREHENSIVE GERIATRIC ASSESSMENT

Background

There is an abundance of evidence to demonstrate the positive impacts of Comprehensive Geriatric Assessment (CGA) on clinical and process outcomes for older adults across settings of care. However, it is unclear how older adults themselves view CGA and their experiences of the care process. The aim of this qualitative evidence synthesis is to explore the experiences and perspectives of older adults of CGA.

Methods

A comprehensive literature search was completed across MEDLINE, CINAHL, PsycINFO, PsycARTICLES and Social Sciences Full Text. Qualitative or mixed methods studies that included qualitative data on the perspectives and experiences of older adults of CGA were included. The methodological quality of the included studies was appraised using the Critical Appraisal Skills Programme checklist for qualitative research. Findings were synthesised using thematic analysis

Results

Nine studies were included in the synthesis, including studies where CGA was completed in hospital, outpatient assessment unit and home settings. Divergent experiences of CGA were reported. Older adults reported experiences of being respected and listened to during CGA and attention paid to all their issues and priorities. Good communication by healthcare providers was central to these positive experiences (theme 1). In contrast, experiences of being unclear about the aim of CGA or perceived benefits of CGA, feeling that the outcome of CGA did not align with their priorities (theme 2) and not feeling involved in decision making during CGA (theme 3) were also commonly reported.

Conclusion

Findings indicate that CGA is a process by which older adults can felt respected and paid attention to. However, scope exists to further improve older adults’ experiences of CGA. Enhanced healthcare provider communication and facilitation of older adult involvement in decision-making are priority areas for improvement. Further research should focus on exploring other stakeholder groups experiences of CGA including caregivers and healthcare professionals.

267 WHAT IS THE IMPACT OF ACUTE HEALTHCARE UTILISATION ON FUNCTIONAL DECLINE IN OLDER ADULTS OVER TIME? A POPULATION-BASED COHORT STUDY

Background

Acute healthcare use varies by age, with older adults the highest users of most acute healthcare services. Using data from The Irish Longitudinal Study on Ageing (TILDA), the aim of this study was to investigate the impact of acute healthcare utilisation at baseline on subjective and objective measures of function at four-year follow-up in older adults.

Methods

This study represents a secondary analysis of a prospective cohort study where data from Wave 1 (baseline) and Wave 3 (four-year follow up) of TILDA were analysed in conjunction with a public and patient involvement group of older adults. Acute healthcare utilisation was defined as an Emergency Department (ED) visit with or without hospitalisation in the previous 12 months. Function was assessed objectively using Timed-Up-and Go (TUG) and grip strength and subjectively using self-report limitations in activities of daily living and instrumental activities of daily living. Linear regression was used to investigate the relationship between ED use at baseline and grip strength and TUG performance at Wave 3. Logistic regression was used to investigate the relationship between ED use at baseline and whether a participant had a disability in ADL and IADL, or not, at Wave 3.

Results

A total of 1516 participants met the study inclusion criteria. Mean age was 70.9 years (SD=4.6) and 48% were male. At baseline, 1280 participants reported no acute healthcare use. 118 indicated an ED visit but no hospitalisation in the previous twelve months and 118 reported both an ED visit and hospitalisation. Adjusting for all covariates, compared to those with no acute healthcare utilisation, those with an ED visit with no hospital admission had poorer TUG performance at follow up (β= 0.67, 95% CI: 0.34, 1.29, p=0.039).

Conclusion

The results of this study support a relationship between acute healthcare utilisation and functional decline assessed by TUG at follow-up.

303 SCREENING INSTRUMENTS TO PREDICT ADVERSE OUTCOMES FOR UNDIFFERENTIATED OLDER ADULTS ATTENDING THE EMERGENCY DEPARTMENT: RESULTS OF SOAED PROSPECTIVE COHORT STUDY

Background

Frailty screening facilitates the stratification of older adults at most risk of adverse events for urgent assessment and subsequent intervention in the acute or community setting. We assessed the validity of the ISAR (Identification of Seniors at Risk), Rockwood Clinical Frailty Scale (CFS), PRISMA-7 and InterRAI-ED at predicting adverse outcomes at 30 days and six months among older adults presenting to the ED.

Methods

A prospective cohort study of consecutive older adults (≥65 years) who presented to the ED at a University Hospital was conducted. The ISAR, CFS, PRISMA-7 and InterRAI-ED were performed by an experienced ED research nurse. Blinded follow-up telephone interviews were completed at 30 days and six months to assess the incidence of mortality, ED re-attendance, hospital readmission, functional decline and nursing home admission. The sensitivity and specificity of the screening tools were calculated using 2×2 tables.

Results

419 patients were recruited with 49% female and a mean age of 76.9 years (SD 7.15). The prevalence of frailty varied across the screening tools (ISAR, 47% vs InterRAI-ED, 63%). At 30-days, mortality rate was 5.4%, ED re-attendance 16.9%, hospital readmission 13.6%, functional decline 47.1% and nursing home admission 7.3%. Older adults who screened positive for frailty demonstrated an increased risk of all adverse outcomes at 30 days and 6 months, regardless of frailty screening tool administered. All tools had a relatively high sensitivity but low specificity. The ISAR was the only tool which was statistically significant at predicting all outcomes at 30 days.

Conclusion

The ISAR, CFS, PRISMA-7 and InterRAI-ED demonstrated modest validity at predicting adverse outcomes at 30 days and 6 months. We would recommend the implementation of one of these frailty screening tools in Irish EDs to support clinicians in identifying older adults most likely to benefit from specialised geriatric assessment and intervention in the hospital or community setting.

319 CAN INDEX BARTHEL SCORE AT EMERGENCY DEPARTMENT PRESENTATION PREDICT ADVERSE OUTCOMES AMONG OLDER ADULTS AT 30 DAYS AND 6 MONTHS?

Background

Frailty is acknowledged as a significant syndrome particularly in the older population. Monitoring frailty in late life aetiology and recognising the value of frailty as a marker of risk for adverse health outcomes is vital and ensures the identification of opportunities for intervention with this cohort in clinical practice. The aim of this prospective cohort study is to examine if an index Barthel Score at Emergency Department presentation predicts adverse outcomes among older adults at 30 days and 6 months.

Methods

Six-hundred and fifty older adults (≥65 years) attending a university model 4 hospital ED were recruited. Baseline evaluation included the Barthel Index. Adverse outcomes (hospital readmission or death) were recorded by a research nurse at 30 days and 6 months, blinded to Barthel score. Descriptive statistics were used to profile the population and report the incidence of adverse outcomes.

Results

At 30 days, 61 older adults had either being admitted to hospital (n=28) or died (n=33) and at 180 days a further 72 had been admitted (n=43) or died (n=29). A total of 29% (n=189) of the population had a Barthel score of ≤15 indicating moderate dependency. Of this cohort, 70% had an adverse outcome-readmitted or died within 180 days.

Conclusion

It may be worth looking at introducing the Barthel Index as a routine measure of activity for older adults presenting to the ED. This tool demonstrates an increased risk of adverse outcomes among older adults who present with moderate dependency. Early intervention either in the hospital or community setting with this ‘at risk’ cohort may serve to reduce adverse outcomes among this group.

361 EXPLORING THE EXPERIENCES OF HEALTHCARE PROFESSIONALS (HCPS) WORKING IN ACUTE STROKE DURING THE COVID-19 PANDEMIC: A QUALITATIVE STUDY

Background

The COVID-19 pandemic had a significant impact on the delivery of stroke care internationally. The INAS (Irish National Audit for Stroke) report 2020, found that there was no significant disruption to stroke services as a result of the COVID-19 pandemic. Little is known about the experiences of Health-Care Professionals (HCPs) who were working in stroke care during the COVID-19 pandemic. This study explored the experiences of HCPs working in acute stroke care in an Irish hospital group during the COVID-19 pandemic.

Methods

A qualitative descriptive study was conducted. Using a combination of purposive and snowball sampling, 16 semi-structured interviews of healthcare professionals from six specialities (Medicine, Nursing, Physiotherapy, Occupational therapy, Speech and Language Therapy and Medical Social Work) in two model three hospitals and one model four hospital were conducted. Interviews were virtual. Analysis was completed using the Braun and Clarke six-step method. This research was approved by the Royal College of Surgeons Research Ethics committee and permission was secured from the Stroke Clinical lead at each site to conduct interviews.

Results

Two main themes emerged: (i) Disruption of the end-to-end acute stroke pathway and (ii) Opportunities of the pandemic to develop a new model of care. Theme (i) suggests challenges were experienced in emergency care, access to Stroke Units (SU) beds and multidisciplinary teams (MDT). In theme (ii) participants described opportunities in telemedicine, the development of new rehabilitation and existing Early Supported Discharge (ESD) pathways.

Conclusion

This study highlights the lived experience of HCPs, the disruption to the stroke pathway and the opportunities as a result of the pandemic. It demonstrates the need for further exploration of, telemedicine, alternative rehabilitation pathways in stroke care and the need for a wider stroke education programme for HCPs working outside stroke. Finally, this study highlights the unwavering resilience and empathy of HCPs working in Stroke.

30 THE DIAGNOSTIC AND PREDICTIVE ACCURACY OF THE EDMONTON FRAIL SCALE FOR SCREENING FRAILTY IN OLDER ADULTS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Frailty is a dynamic, multidimensional syndrome that is highly prevalent in older adults (65 years or older), which increases one’s dependency and vulnerability to adverse health outcomes, including mortality. The Edmonton Frail Scale (EFS) is a commonly used screening tool for identifying frailty in older adults.

The purpose of this systematic review and meta-analysis is to determine the diagnostic test accuracy of the EFS to identify frailty in older adults, as well as the predictive accuracy of the EFS for adverse outcomes associated with frailty.

Methods

A literature search was performed across PubMed, EMBASE, CINAHL, MEDLINE and the Cochrane Library to identify all studies that validated the EFS across clinical settings. The methodological quality of the included studies was assessed using the QUADAS-2 tool. A bivariate random effects model generated pooled estimates of sensitivity and specificity.

Results

Eleven studies were included in the systematic review and six studies were included in meta-analysis. The diagnostic test accuracy of the EFS could not be proven from the included studies. The EFS was found to be more useful at ruling in rather than ruling out increased risk of mortality in individuals classified as frail, with a higher pooled specificity (0.75, 95% CI 0.64-0.84) than sensitivity (0.49, 95% CI 0.42-0.56).

Conclusion

The Edmonton Frail scale has limited ability as a frailty screening tool and should not be used in isolation to screen for frailty in older adults in clinical settings.

265 A PHYSIOTHERAPY-LED TRANSITION TO HOME INTERVENTION FOR OLDER ADULTS FOLLOWING EMERGENCY DEPARTMENT DISCHARGE: A PILOT FEASIBILITY RANDOMISED-CONTROLLED TRIAL

Background

Older adults frequently attend the Emergency Department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. A presentation to an ED can be viewed as an opportunity to assess those at risk of adverse outcomes and initiate a care plan in those deemed as ‘high risk'. Our aim was to evaluate the feasibility of a physiotherapy led integrated care intervention for older adults discharged from the ED (ED-PLUS).

Methods

Older adults presenting to the ED with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED-PLUS (Trial registration: NCT04983602). ED-PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient’s own home. Feasibility (recruitment and retention rates) and acceptability of the programme were assessed quantitatively and qualitatively. Functional decline was examined post-intervention using the Barthel Index. All outcomes were assessed by a research nurse blinded to group allocation.

Results

29 participants were recruited, indicating 97% of our recruitment target. 90% of participants completed the ED-PLUS intervention. All participants expressed positive feedback about the intervention. The incidence of functional decline at 6 weeks was 10% in the ED-PLUS group versus 70-89% in the usual care and CGA-only groups.

Conclusion

High adherence and retention rates were observed among participants and preliminary findings indicate a lower incidence of functional decline in the ED-PLUS group. Recruitment challenges existed in the context of COVID-19. Data collection is ongoing for six-month outcomes.

315 “I JUST GOT ON WITH IT”: EXPLORING THE PATIENT EXPERIENCE OF STROKE REHABILITATION DURING THE COVID-19 PANDEMIC

Background

There are emerging studies examining the pandemic experiences for older adults and healthcare staff, however the impact of COVID-19 on stroke rehabilitation has yet to be examined. Family involvement and social support is central to adjustment during stroke rehabilitation and this was impacted by the pandemic and its restrictions. The aim of this study was to explore first-person lived experiences of stroke rehabilitation in an Irish rehabilitation hospital setting during the COVID-19 pandemic and understand how COVID-19 restrictions impacted on patients’ experiences of stroke rehabilitation.

Methods

A qualitative descriptive design was implemented with a purposive sample of stroke survivors, who had undergone stroke rehabilitation between January – December 2021 at an Irish post-acute rehabilitation hospital. Semi-structured interviews were used as the primary data collection method and were audio-recorded and transcribed verbatim. Data were analysed using Braun & Clarke’s (2018) six-step approach and external data validator was used for inter-coder reliability.

Results

Eight stroke survivors were interviewed (male n=5, female n=3). Four main themes were identified: (i) Resilience and coping, (ii) Feeling supported along the journey, (iii) The pinch of COVID-19, (iv) Adjustment and moving on. The stroke survivors’ resilience was an important recurring theme throughout the analysis. A sense of feeling supported by hospital staff and peers was also prominent. The impact of COVID-19 restrictions was felt by all participants, however, resilience, support from hospital staff and peers were the strongest recurring themes.

Conclusion

COVID-19 restrictions had an impact on the stroke rehabilitation experience, however, stroke survivors felt well-supported and showed resilience in spite of this. To the best of the researchers’ knowledge, this is the first study which examines first-person accounts of stroke survivors during the COVID-19 pandemic, thus offering a unique perspective on the experiences of this cohort, who were hospitalised during this time.

353 FACTORS ASSOCIATED WITH ADVERSE OUTCOMES IN OLDER ADULTS DIRECTLY DISCHARGED FROM THE EMERGENCY DEPARTMENT

Background

Older adults attend the Emergency Department (ED) frequently. Over 40% are directly discharged from the ED. The risk of adverse outcomes is high following discharge including unplanned ED return, institutionalisation, and mortality. The purpose of this study was to highlight factors that predict these adverse outcomes.

Methods

A secondary analysis was completed of SOAED (a prospective cohort study examining screening instruments to predict adverse outcomes for undifferentiated older adults attending the ED) and OPTIMEND (randomised control trial examining the effectiveness of an intervention by a team of Health and Social Care Professionals along with usual care and compared this to standard ED care alone). Inclusion criteria were adults aged 65 years and over presenting to ED at a University Teaching Hospital with medical complaints and a Manchester Triage System category 2–5.

Results

Three-hundred and nine patients were discharged directly from ED (mean age 80 years; 58% female). 96 patients re-attended ED within 6 months. 66 patients were re-hospitalised within 6 months. 16 patients died within six months of discharge. 63% of the discharged patients screened positive for frailty measured by PRISMA-7 (3 or more). Relative risk ratio analysis confirmed that the risk of revisiting a hospital was 1.241 times for patients that scored frail compared to those who scored not frail. The risk of mortality was 1.075 times for patients that scored frail compared to those who scored not frail. The risk of being admitted to a nursing home was 1.146 times for patients that scored frail compared to those who scored not frail.

Conclusion

Older people have a high ED re-attendance rate of 31% after an index visit. Frailty (scored on PRISMA-7) is a significant predictor of adverse outcomes. Focused screening and intervention for frail patients who attend the ED should be a priority.

9 EFFECTIVENESS OF INTERVENTIONS TO SUPPORT THE TRANSITION HOME AFTER ACUTE STROKE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

There are considerable gaps in knowledge about effective support interventions to manage the transition to home after stroke. This systematic review looked at the effectiveness of support interventions at transition from structured stroke services to independent living at home.

Methods

We searched, up to June 2021, the Cochrane Central Register of Controlled Trials, and six databases including MEDLINE and Embase; and extended to trial registries, grey literature, and Google Scholar.

We included randomised controlled trials recruiting stroke patients to receive either usual care or any support intervention from structured stroke services to home. The primary outcome was functional status.

Two authors determined eligibility, extracted data, assessed risk of bias (ROB2) and certainty of evidence (GRADE). Where possible we performed meta-analyses using Risk Ratios (RR) or Mean Differences(MD).

Results

We included 17 studies. Support interventions led to important improvements in functional status, measured by Barthel Index up to 3-months (MD 7.87 points, 95%CI:6.84 to 19.16; 620 participants; five studies; I2=77%). Results in the medium to long-term demonstrated small but significant functional gains (6-12 month follow-up; MD 2.91 points, 95%CI:0.03 to 5.81; 1207 participants; six studies; I2=84%). Certainty of evidence was low.

Support interventions may improve quality of life up to 3-months (MD 1.3,95% CI:0.84 to 1.76), and reduce depression (SMD –0.1,95% CI:-0.29 to –0.05) and anxiety (MD –1.18,95% CI:-1.84 to –0.52) at 6 –12 months. Effects on other secondary outcomes remain inconclusive.

Conclusion

Incorporating support interventions at hospital-to-home discharge can improve functional status and other outcomes when transitioning home after a stroke. Due to study heterogeneity, the key elements of a successful transition of care interventions remain unclear. Adoption of core outcome sets in stroke research would allow for greater comparison across studies; while applying a development and evaluation framework, and engaging stakeholders, would increase understanding of stroke survivor priorities and key elements of a transition intervention.

Adjunctive therapies in addition to land-based exercise therapy for osteoarthritis of the hip or knee

BACKGROUND

Land-based exercise therapy is recommended in clinical guidelines for hip or knee osteoarthritis. Adjunctive non-pharmacological therapies are commonly used alongside exercise in hip or knee osteoarthritis management, but cumulative evidence for adjuncts to land-based exercise therapy is lacking.

OBJECTIVES

To evaluate the benefits and harms of adjunctive therapies used in addition to land-based exercise therapy compared with placebo adjunctive therapy added to land-based exercise therapy, or land-based exercise therapy only for people with hip or knee osteoarthritis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro) and clinical trials registries up to 10 June 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs of people with hip or knee osteoarthritis comparing adjunctive therapies alongside land-based exercise therapy (experimental group) versus placebo adjunctive therapies alongside land-based exercise therapy, or land-based exercise therapy (control groups). Exercise had to be identical in both groups. Major outcomes were pain, physical function, participant-reported global assessment, quality of life (QOL), radiographic joint structural changes, adverse events and withdrawals due to adverse events. We evaluated short-term (6 months), medium-term (6 to 12 months) and long-term (12 months onwards) effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias and certainty of evidence for major outcomes using GRADE.

MAIN RESULTS

We included 62 trials (60 RCTs and 2 quasi-RCTs) totalling 6508 participants. One trial included people with hip osteoarthritis, one hip or knee osteoarthritis and 59 included people with knee osteoarthritis only. Thirty-six trials evaluated electrophysical agents, seven manual therapies, four acupuncture or dry needling, or taping, three psychological therapies, dietary interventions or whole body vibration, two spa or peloid therapy and one foot insoles. Twenty-one trials included a placebo adjunctive therapy. We presented the effects stratified by different adjunctive therapies along with the overall results. We judged most trials to be at risk of bias, including 55% at risk of selection bias, 74% at risk of performance bias and 79% at risk of detection bias. Adverse events were reported in eight (13%) trials. Comparing adjunctive therapies plus land-based exercise therapy against placebo therapies plus exercise up to six months (short-term), we found low-certainty evidence for reduced pain and function, which did not meet our prespecified threshold for a clinically important difference. Mean pain intensity was 5.4 in the placebo group on a 0 to 10 numerical pain rating scale (NPRS) (lower scores represent less pain), and 0.77 points lower (0.48 points better to 1.16 points better) in the adjunctive therapy and exercise therapy group; relative improvement 10% (6% to 15% better) (22 studies; 1428 participants). Mean physical function on the Western Ontario and McMaster (WOMAC) 0 to 68 physical function (lower scores represent better function) subscale was 32.5 points in the placebo group and reduced by 5.03 points (2.57 points better to 7.61 points better) in the adjunctive therapy and exercise therapy group; relative improvement 12% (6% better to 18% better) (20 studies; 1361 participants). Moderate-certainty evidence indicates that adjunctive therapies did not improve QOL (SF-36 0 to 100 scale, higher scores represent better QOL). Placebo group mean QOL was 81.8 points, and 0.75 points worse (4.80 points worse to 3.39 points better) in the placebo adjunctive therapy group; relative improvement 1% (7% worse to 5% better) (two trials; 82 participants). Low-certainty evidence (two trials; 340 participants) indicates adjunctive therapies plus exercise may not increase adverse events compared to placebo therapies plus exercise (31% versus 13%; risk ratio (RR) 2.41, 95% confidence interval (CI) 0.27 to 21.90). Participant-reported global assessment was not measured in any studies. Compared with land-based exercise therapy, low-certainty evidence indicates that adjunctive electrophysical agents alongside exercise produced short-term (0 to 6 months) pain reduction of 0.41 points (0.17 points better to 0.63 points better); mean pain in the exercise-only group was 3.8 points and 0.41 points better in the adjunctive therapy plus exercise group (0 to 10 NPRS); relative improvement 7% (3% better to 11% better) (45 studies; 3322 participants). Mean physical function (0 to 68 WOMAC subscale) was 18.2 points in the exercise group and 2.83 points better (1.62 points better to 4.04 points better) in the adjunctive therapy plus exercise group; relative improvement 9% (5% better to 13% better) (45 studies; 3323 participants). These results are not clinically important. Mean QOL in the exercise group was 56.1 points and 1.04 points worse in the adjunctive therapies plus exercise therapy group (1.04 points worse to 3.12 points better); relative improvement 2% (2% worse to 5% better) (11 studies; 1483 participants), indicating no benefit (low-certainty evidence). Moderate-certainty evidence indicates that adjunctive therapies plus exercise probably result in a slight increase in participant-reported global assessment (short-term), with success reported by 45% in the exercise therapy group and 17% more individuals receiving adjunctive therapies and exercise (RR 1.37, 95% CI 1.15 to 1.62) (5 studies; 840 participants). One study (156 participants) showed little difference in radiographic joint structural changes (0.25 mm less, 95% CI -0.32 to -0.18 mm); 12% relative improvement (6% better to 18% better). Low-certainty evidence (8 trials; 1542 participants) indicates that adjunctive therapies plus exercise may not increase adverse events compared with exercise only (8.6% versus 6.5%; RR 1.33, 95% CI 0.78 to 2.27).

AUTHORS' CONCLUSIONS

Moderate- to low-certainty evidence showed no difference in pain, physical function or QOL between adjunctive therapies and placebo adjunctive therapies, or in pain, physical function, QOL or joint structural changes, compared to exercise only. Participant-reported global assessment was not reported for placebo comparisons, but there is probably a slight clinical benefit for adjunctive therapies plus exercise compared with exercise, based on a small number of studies. This may be explained by additional constructs captured in global measures compared with specific measures. Although results indicate no increased adverse events for adjunctive therapies used with exercise, these were poorly reported. Most studies evaluated short-term effects, with limited medium- or long-term evaluation. Due to a preponderance of knee osteoarthritis trials, we urge caution in extrapolating the findings to populations with hip osteoarthritis.

Exploring the perspectives of people with stroke, caregivers and healthcare professionals on the design and delivery of a mHealth adaptive physical activity intervention: a qualitative study protocol

Background: Despite recent advances in acute stroke intervention, secondary prevention strategies are lacking. Physical activity (PA) is the second-largest predictor of stroke and a cornerstone of secondary prevention therapies. Interventions to promote PA post-stroke include components aimed at reducing sedentary behaviour and increasing participation in lifestyle PA and structured exercise. Despite guidelines to adapt PA to individuals’ needs, there is no evidence on the empirical development of adaptive PA interventions post-stroke. This study will explore patient, caregiver and multidisciplinary healthcare professional perspectives on the design and delivery of adaptive, personalised PA interventions, delivered using a smartphone application, following mild-to-moderate stroke. Findings will directly inform the protocol of an experimental trial, using a novel adaptive trial design.   Methods: A descriptive qualitative study will be undertaken to inform the design, delivery and subsequent acceptability of a smartphone application to reduce sedentary behaviour and promote PA post-stroke. Data will be collected via one-to-one interviews and focus groups and analysed according to a six-step thematic analysis. Findings will be reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) checklist. One-to-one interviews and focus group interviews will be conducted with three stakeholder groups: 1) People post-stroke, who are independently mobile, without communication and cognitive deficits, living in the community, and without other diagnosed neurological conditions. 2) Caregivers (formal and informal) involved in post-stroke care.  3) Healthcare professionals who are members of multidisciplinary stroke teams. Ethics and dissemination: Ethical approval has been granted by the Faculty of Education and Health Sciences Research Ethics Committee at the University of Limerick [Ref: 2019_10_03_ EHS]. Findings will be shared locally with all stakeholder groups, submitted for publication, and will inform the protocol and conduct for a novel and flexible experimental trial, examining the effectiveness of an adaptive PA intervention post-stroke.