From Bedbound to Mobile: The Role of the Newham Virtual Frailty Ward
Abstract
- Introduction
83 yo male who presented to hospital following 2 falls within a week. He had a background history of hiatus hernia. He was independent of all activities of daily living residing in sheltered, warden controlled accommodation. Upon presentation to hospital he given antibiotics for chest infection and had a mild acute kidney injury. His electrocardiogram showed a 2:1 AV block and he was transferred to a tertiary centre for a pacemaker Upon return to hospital he had a period of significant deconditioning coupled with orthostatic hypotension which hampered his ongoing rehabilitation. He was discharged home with a doubled handed four times a day package of care, along with a hospital bed and single floor living. He was commenced on midodrine to aid with the postural hypotension he was experiencing. He was referred to the virtual frailty ward, a home based hospital ward, for ongoing clinical review and therapies
- Method
Through a structured and individualised care plan via the MDT which included medication review and tailored exercise therapy plans helped regain muscle strength which he had lost in hospital
- Results
RS gradually regained his strength and the postural hypotension significantly reduced. Eventually RS was able to sit at the edge of the bed and transfer into the riser recliner chair which had been ordered for him. He eventually began to walk short distances with a wheeled zimmer frame to progressing to mobility outdoors
- Conclusion
Through a balanced MDT approach RS was able to go from being bed bound at discharge from hospital to walking with minimal assistance over a period of 5 weeks at home with the intervention of the virtual frailty team
Comments
Frailty ward
Thank you for this interesting presentation. The results are encouraging; however, I would be interested to better understand the resources required to deliver and sustain the programme in routine practice. Specifically, what staffing model was used within the 26-bed ward, how frequently participants received physiotherapy input, and what role nursing staff played in reinforcing mobility and exercise outside formal therapy sessions. Further detail regarding the exercise programme itself, including intensity, progression and adherence, would also be helpful.
Given the increasing pressures on health services, it would be valuable to understand the cost implications and potential barriers to implementation, particularly in settings with limited physiotherapy and allied health resources. I am also interested in whether nutritional assessment and intervention formed part of the programme, given the important contribution of malnutrition, sarcopenia and frailty to falls risk and functional outcomes in older adults.
Finally, were outcomes examined according to discharge destination, particularly for patients discharged to residential aged care facilities? Understanding whether the benefits were maintained in this cohort would help inform the broader applicability and scalability of the programme.
Thank you
We have a small team; 3 band 7 nurses, one advanced clinical practitioner in frailty, one physio therapist, one rehab support worker, one occupational therapist, one consultant geriatrician and one clinical pharmacist. Whilst all of the 26 patients may not need therapies input as they are at their usual standard of mobility, we are increasingly seeing referral from an inpatient cohort to progress patients mobility after discharge. This is a result of a number of issues, 1. Staffing of therapies across our elderly care wards, not being able to constantly deliver regular physio and mobility practice to everyone that needs it. 2. Reliance on inpatient nursing staff to aid mobility, but they are already tasked with, care, changing, feeding, documentation etc, and are wary of the patients with "high falls risk" so don't mobilise 3. Motivation of the patients, many of our frail patients don't wish to engage with mobility practice as they are "unwell". All of these factors do lead to a significant number of patients becoming deconditioned. We at the virtual ward manage to visit our patients 2-3 times a week to help improve mobility practice, and we do rely on patients being motivated, as our case here, as well as engagement from friends, family and carers in the community. Unfortunately, pressures across the board mean that we are seeing an increasing number of patients leaving hospital deconditioned and bedbound, which in turn places more strain on the care packages they require which in turn leads to increased frailty in a vicious cycle. If we had more inpatient therapies staff and a culture shift to maintaining/ improving mobility then deconditioning would most definitely be less, which in turn leads to patients being less reliant on packages of care, and them being able to maintain independence, which would most definitely offset the cost implications of these community funded services.
Lastly, our patient, had inpatient and outpatient dietician reviews and in fact put on lots of weight post discharge, but this may have been something to do with him not being keen on hospital food!
Lovely…
Lovely case , going from bed-bound at discharge to walking with minimal assistance in 5 weeks is a fantastic outcome, and a great example of what the home-based virtual frailty team can achieve. Just curious: is the ward mainly for patients with postural drop and deconditioning, or do you also accept those with impaired mobility from other causes, such as cancer? Thanks for sharing!
Thank you
We have 26 patients on the ward, all with varying medical issues that they were referred for. Most of our patients, we are asked to manage heart failure symptoms and we do progress mobility with those patients once their underlying condition is stable. So, yes not only postural hypotension and deconditioning, but these occur as a result of prolonged hospital admission and lack of mobility in the inpatient setting. We do try and progress mobility in those that wish to stay motivated and want to progress their mobility