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Active Hospitals

Inpatient case study – Medical Ward Pathway

More than a third of the UK population now lives to the age of 85, with up to half of adults in that group estimated to become frail in the last 10 years of their lives, and the numbers keep increasing. Frailty is an important prognostic indicator for hospital admission, higher care needs, poor quality of life and mortality rates.

Independently living frail patients who are admitted to hospital are less likely to recover their mobility, and more likely to need life in the care of nursing homes after discharge.

Improvements in mobility and balance during the first 48 hrs of admission have been associated with greater overall functional improvement and shorter recovery times.

Ward Based exercises

Interventions

Behavioural change interventions were designed and mapped to influence patient care during the inpatient admission of patients on the Complex Medical Unit.

Motivational Interview (More minutes conversation)

During their admission our Physical Activity Champion conducted motivational interviews (that followed the structure of a More minutes conversation) with patients, who were identified if they had a stable Early Warning Score and were not on an end of life pathway.

Our Physical Activity Champion was trained in motivational interview techniques by the central Active Hospital team, as well as completing the online Active Conversations course to consolidate learning further.

Patient Workbook was used during motivational interviews to give consistent structure to the conversation, help patients set their ambitions and plan how to achieve their goals.

Exercise program leaflets (StandingChair and Bed-based) were available for patients depending on their functional level.

All conversations regarding physical activity were documented in the patient’s Electronic Patient Record.

Exercise programmes

StandingChair-based and Bed-based exercise programs were developed to provide all staff working on the ward with a tool to encourage patients to move more whilst staying as an inpatient.

The exercise booklets are designed to encourage ‘something rather than nothing’, as recommended by UK CMO Physical Activity Guidelines For Older Adults,  Physical Activity For Adults And Older Adults and the Royal Osteoporosis Society ‘strong, steady and straight’ document (1). They are not designed to bring about a training effect, rather to support carers, patients and their families with some appropriate, easy-to-follow exercises to practice whilst in hospital.

There is a focus on anti-gravity muscles in the lower limb, as these muscle groups are at particular risk of atrophy following a period of immobilisation, as well as some gentle aerobic work and upper limb strength (1).

They were designed to require little or no equipment and are transferable to the home environment. The exercises were developed to ensure that all patients regardless of level of frailty or functional impairment could participate.

The exercise programs can be linked with the functional outcomes of the Bedside Mobility Assessment Tool (BMAT) which is a modified version of the Banner Mobility Assessment Tool, a validated tool that is quick to use and acceptable to patients (2).

 

References:

  1. Royal Osteoporosis Society. Strong, Steady and Straight; An Expert Consensus Statement on Physical Activity and Exercise for Osteoporosis. Accessed at https://theros.org.uk/forms/documents/strong-steady-and-straight/ on 23.07.2019.
  2. Boynton T, Kelly L, Amber Perez LP, Miller M. Banner mobility assessment tool for nurses: Instrument validation. Am J SPHM. 2014;4(3):87.

 

The I CAN enablement tool

The I CAN is a patient centred enablement tool was developed to help staff identify functional level of patient quickly and easily. This allows staff to facilitate the appropriate level of functional assistance required for each patient to support their independence as far as possible.

It is designed to be displayed at the end of the bed, and our I CANs were laminated to comply with infection control policy.

A number of iterations of this document were developed in response to staff feedback. The I CAN User Guide was available to staff to provide guidance on the use of I CANs.

 

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Physical Activity Calculator

The Physical Activity Calculator is a modified version of the exercise vital sign (1, 2, 3) that was designed and incorporated into the Trust’s electronic record system. This validated self-reported tool was chosen it was felt practical and realistic for staff to deliver.

Physical activity levels are assessed and coded into three categories with a very brief advice prompt given depending on patient’s physical activity levels. The three categories are:

(1) Green (more than 150 minutes/week)

(2) Amber (30-150 minutes/week)

(3) Red (less than 30 minutes/week).

Brief advice, in the form of a 1 minute conversation, is given depending on physical activity levels.

 

References:

  1. Sallis R, Franklin B, Joy L, et al. Strategies for promoting physical activity in clinical practice. Prog Cardiovasc Dis 2015;57:375–86.
  2. Coleman, K.J., et al., Initial validation of an exercise “vital sign” in electronic medical records. Med Sci Sports Exerc, 2012. 44(11): p. 2071-6
  3. Department of Health and Social Care: UK CMO Physical Activity guidelines for older adults. Accessible from https://www.gov.uk/government/publications/uk-physical-activity-guidelines
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Physical Actvity Champion

Our Physical Activity Champion was employed for one day per week on the medical ward. The clinical champions were critical to the success of the project, and when recruiting we were looking for an enthusiastic, innovative and experienced professional with outstanding leadership and interpersonal skills.  The role included opportunities to develop clinical skills in behavioural change counselling and exercise medicine as well as develop managerial skills such as education, systems review and leadership.

Our Physical Activity Champion was trained in motivational interview techniques from the central Active Hospital team, as well as completing the online Active Conversations course to consolidate learning further.

All Physical Activity Champions were supported through regular appraisal, using our Clinical Supervisor Meeting template and Personal Development Plan template.

Community Navigator

Feedback from staff before training highlighted that one of the barriers to supporting and advising physical activity to patients was a lack of knowledge of what was available locally to which they could refer.  A community navigator role was developed for the Active Hospital pilot across all our clinical pathways, providing one-to-one consultations with patients as well as providing advice and guidance to staff on where to find support for patients in the community. Their role was critical to ensure continuity of care through hospital admission to discharge to community environment.

 

An online map was developed to allow all staff and patients access to the wide range of community based classes and support throughout the region.

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Governance Framework

High level and senior support for development and integration of interventions within the patient journey is clearly important to build change within a hospital outpatient environment and ensuring safe and effective patient care.

We liaised closely throughout with senior figures throughout the design, delivery and maintenance phases of this pathway.

We maintained a presence on the maternity departmental governance meetings to ensure full integration of interventions within a robust governance framework.

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Environment changes

A notice board within the ward was used to display promotional materials. These resources were designed to encourage staff, relatives and patients, to disseminate key messages and aimed to change social culture surrounding physical activity. They provide relevant positive advice regarding the benefits of activity and demonstrate ways to build activity into daily life.

Here are a selection of our posters:

Poster – Hoover Groover

Poster – Join the Moving Movement

The Trust’s Chief Executive (Dr Bruno Holthof) visiting staff, including our Physical Activity Champion, on the Active Hospitals ward.

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Staff training

In the next phase of work on the medical wards we are planning to provide formal training to all staff members, exploring the benefits of physical activity to their patients, particularly in preventing hospital associated deconditioning.

These practical training sessions will provide an introduction to Active Conversations, teaching motivational interviewing techniques, to encourage staff to talk to their patients about physical activity. More information on training can be found within the governance section.

Outcomes

In this section you will find some of the outcomes from the pathway

Service analysis

A snapshot analysis over a five day period was conducted to identify the number of patients who were suitable to receive a physical activity intervention (i.e. active conversation, goal setting, exercise advice with bed/seated/or standing leaflet and I CAN tool) and those who actually received one. Exclusion criteria were as follows; a ‘track & trigger’ score greater than 1, cognitive impairment, end of life care and patient refused intervention.

We found that the exclusion criteria were sensitive but not specific (excluded suitable patients). Data also demonstrated that commonly only the Physical Activity Champion was encouraging patients to be physically active. Activity was significantly higher on days when the Physical Activity champion was present. This suggested that further support was needed to increase the frequency of physical activity conversations on the ward.

As a result, phase 2 on the medical ward aims to use a Frailty index to identify suitable patients. The Trust has supported the project by funding a number of dedicated rehabilitation assistant posts across the medical wards to deliver physical activity interventions. To support this we are planning to deliver a comprehensive education programme for all members of staff on the benefits of physical activity and functional mobility for frail patients admitted to hospital. Clinical tools (such as the PAC, and BMAT) are being integrated into electronic patient record systems to support staff to promote physical activity and reduce hospital associated deconditioning.

Patient Survey

We surveyed patients (n = 26) on the ward during Feb 2019.

85% of patients felt physical activity was important in recovery, 76% felt that they were encouraged by staff to be more active on the ward, with 84% feeling that they wanted to be active on discharge following the Active Hospital interventions.

“The Advanced Rehab Support Workers have been supporting with music sessions via the iPad (whilst the musicians can’t come into the hospital) and trialling some distraction equipment on the wards, alongside running some other more meaningful activities.
I am blown away with how effective they are at engaging patients.
To me there is a real difference on [the wards] now, and I do think they play a huge part in creating a positive, energised atmosphere.I honestly can’t rate them enough, there is so much potential for similar roles.”

Memory Nurse Specialist, 2020

Below are some top tips from our Active Hospital Team

1
Talk and collaborate

Talk to other stakeholders to identify initiatives that may already be under development – it might be that your initiative can link into a piece of work that’s already being considered making both more effective. Engage with senior leadership for the various teams, for example the Sister or Matron, head of therapies, medical teams, falls team. You also need to identify the key individuals who will actively promote what you’re doing.

2
Be visible

Having a Physical Activity Champion embedded on the ward can be helpful, although their role needs to be really clear. They should be a role model, supporting others around them – but not the only person responsible for delivering your initiative.

3
Make it part of normal care

Tailor your initiative so that it blends into normal practice, as the most commonly reported barrier to talking about physical activity is lack of time.

4
Have high expectations of patients

A common barrier is the perception that patients are not motivated to become more active. Often this is not true, some patients can be extremely motivated to change, especially if staff members have the skills and confidence to have good quality conversations about physical activity with them.

Resources

I CAN enablement tool
I CAN user guide
Goal Setting Booklet
UK CMO Physical Activity Guidelines for Older Adults
Clinical Supervisor Meeting template
Personal Development Plan template
Poster – Hoover Groover
Poster – Join the Moving Movement
Chair exercise program
Bed exercise program
Standing exercise program
Bedside Mobility Assessment Tool (BMAT)