Digital Health

Introduction:

This audit was performed by the Northumbria-Healthcare NHS Foundation Trust (NHFCT) Falls and Syncope Service to inform the development of the NHFCT Integrated Falls Strategy (IFS).

Method:

From the opening of the Northumbria Specialist Emergency Care Hospital (NSECH) on 16/06/2015 all ED records were prospectively screened to identify the first 1000 patients aged 65 years and over that had attended with a fall. The 5-year outcome data was obtained from NHFCT electronic records.

Results:

Of the 1000 attends aged 65 years and over with a fall (13.7 attends daily), 55 were patients who reattended having had a further fall. Index characteristics of 945 fallers include: - 64% female, mean age 81.8+/-8.4 years, 79% resided at home, 47% attended with accidental falls, 26% attended with a fracture, 10% with a hip fracture. 5-year outcome data was available for 870 of 945 patients. Of these 870 patients, 28% died within one year and 64% died within 5 years. Men, those who lived in residential or nursing care, those who’s index fall was associated with a hip fracture, those that were admitted to hospital and those who initially presented with unexplained or recurrent falls were more likely to have died at 30 days, one year and 5 years. Of 870 patients, 51% reattended ED with a further fall (mean 2.4 reattends with a fall) and 17% with a subsequent fracture within 5 years. Women, those who lived in sheltered accommodation and those who initially presented with unexplained or recurrent falls were more likely to reattend with a further fall or fracture.

Conclusion:

If the NHFCT IFS aims to reduce further ED attends with a fall and fractures, then this data suggests that the focus should be on those who present with unexplained or recurrent falls and those who live in sheltered accommodation.

Introduction: Modifiable risk factors are an important part of secondary prevention of ischaemic stroke. Many of these are modifiable lifestyle choices. We identified a lack of provision of written information to patients on the stroke ward regarding modifiable lifestyle risk factors, and undertook a quality improvement project which aimed to improve provision of information - both written and verbal - via a "Stroke Passport" document to help patient understanding.

Method: Data was collected from inpatients admitted with ischaemic stroke in the stroke ward in Prince Charles Hospital (District General Hospital), Merthyr Tydfil. A self-rated questionnaire was used to collect data on patients' perceived understanding about risk factors, and the quality of verbal and written information received during their admission pre and post introduction of a “stroke passport” document, containing written information on modifiable risk factors for stroke. Patients with delirium or unable to understand were excluded. Patients were verbally consented and helped with understanding the questionnaire by a stroke specialist nurse.

Results: Baseline data was collected from 21 patients. After introduction of the “Stroke Passport” document, data was collected from 21 different patients. Patients' perceived knowledge improved from 67% to 95% following the introduction of the stroke passport, patients’ perception of receiving verbal information from staff went from 62% to 95% and patients' perception of receiving written information increased from 0% to 100%.

Conclusion: This quality improvement project demonstrated improvements in patients’ perceived knowledge of modifiable risk factors, and in perceived quality of patient education. We suggest that a “stroke passport” document to help guide patients through their stroke journey is of benefit to patient's understanding of risk factors, and standardising the provision of written patient information. Further cycles aim to improve the educational quality of the material by assessing improvement in patient knowledge.

Introduction: Digital technologies can play a significant role in addressing care needs of older people. The process of establishing an effective and efficient digital engagement with older people demands multi-sectoral collaboration from various stakeholders including non-governmental organizations. The role non-governmental organizations play in such digital programs, their process of engagement with older people and factors which influence such multi-sectoral collaboration is an under researched area.

Methods: A scoping review was performed to map existing literature on older people’s engagement with digital health technologies delivered through NGOs. The focus was on exploring the factors influencing the process of digital engagement, delineating modes of digital engagement and exploring the caring needs of older people. Multiple databases and grey literature sources were searched to retrieve articles from 2000 till 2023. JBI methodology for scoping reviews was adopted for this review.

Results: Out of 8970 citations, 50 articles (27 original articles, 9 reports, 12 website sources, 1 handbook and 1 research summary) were included in the final review. NGOs engage with older people either directly by delivering the program or indirectly through other program stakeholders through various inter-organizational processes (collaboration, co-ordination, partnership, delegation, sector-wide participation and association). Different types of NGOs (national, regional, provincial and local) were involved in this process of delivering care. Majority of the studies implemented programs through smartphone or tablet based digital applications. Individual factors, organizational factors, technological factors and system-wide factors influence the process of digital engagement between older people and NGOs.

Conclusion: The number of studies included in this scoping review, concerning older people’s engagement with digital health technologies, through NGOs were informative, but limited information was present on the process of engagement. Acknowledgement of NGOs work, and the societal role they play do also indicate that our developing digital societies more or less depend on these organizations.

Introduction

Community-based comprehensive geriatric assessment (CGA) reduces hospital admissions but the optimal way in which CGA can be delivered is not well understood. Digital and Remote Enhancements for the Assessment and Management of older people living with frailty (DREAM) is a programme of research seeking to develop an enhanced community CGA intervention.

We aimed to identify candidate cognitive assessment tools (CATs) that could be undertaken remotely and enhance CGA.

Methods

Searches were carried out on Medline, PsycINFO, CINAHL and Cochrane databases. Papers published since 2008 were included if they analysed the validity, reliability or acceptability of CATs that could be undertaken remotely in a domestic setting and were tested on older people.  

Results

Of 4286 papers identified, 56 were included. Four types of CAT were identified: computer/tablet/smartphone applications (23tools/27papers), telephone (16tools/23papers), video (2tools/2papers) and specialist equipment (4tools/4 papers). 14 tools demonstrated excellent accuracy for identifying mild cognitive impairment or dementia (specified as AUC >0.80 or sensitivity/specificity>80%). 42 papers presented concurrent/convergent validity, 14 reliability and 16 acceptability data. Time taken to perform tests ranged between 2-30 mins. Of the 23 computer/tablet/smartphone applications, 7 tools are currently available to download.

Key conclusions

Remote CATs could be used in CGA.  Computer/tablet/smartphone applications and some specialist equipment could enhance assessment by quickly and accurately identifying cognitive impairment, in some cases with greater accuracy than traditional tests. Tools that use ‘games’ may be more appealing than conventional pen and paper tools. ​However, many of the computer/tablet/smartphone applications tested are not available for clinical use.

Background:

Patients not yet receiving medication provide insight to drug-naïve early physiology of Parkinson's Disease (PD). Decisions to start medication and assessment of response to its initiation can be challenging for physicians and patients alike.

Aim:

To identify objective, sensor-derived features of upper limb bradykinesia, postural stability, and gait that can inform decision-making in a movement disorder clinic. Methods: We used a single finger sensor to identify upper limb features and an array of six body-worn sensors to measure postural stability and gait. Patients were tested over nine visits, at three-monthly intervals, as part of a standard neurological examination.

Results:

Three upper limb bradykinetic features (finger tapping speed, pronation supination speed, and pronation supination amplitude) and three gait features (gait speed, arm range of motion, duration of stance phase) were found to progress in unmedicated early-stage PD patients. In all features, progression was masked after the start of medication.

Conclusion:

Commencing antiparkinsonian medication is known to lead to masking of progression signals in clinical measures in de novo PD patients. In this study, we show how this effect can be measured using digital devices. The testing kit can be used in movement disorder clinics to inform decision-making and progression monitoring in early PD.

Introduction

Teaching and Research in Care Homes (ToRCH) is a living labs partnership between University of Nottingham and three nursing homes in Derbyshire and Nottinghamshire. We aim to engage care home teams in research, including knowledge exchange and co-designing research proposals.

Methods

We conducted 7 workshops / focus groups with 10 staff members. These were supplemented by site visits, where the researcher observed staff meetings and met with residents and relatives (for patient and public involvement). We elicited discussion by appreciative inquiry method and recorded findings through field notes. Ideas built over time, iteratively, through ongoing discussion.

Results

Digital care records, in place in all member care homes, were a focus of discussion and we identified three topics for improvement projects and accompanying research: A) Emerging from lockdown, care homes identified newly appointed staff may have missed aspects of training about digital documentation, e.g. using language consistent with the model of care. Additional support may optimise use of digital records consistent with relationship-based practice. B) Using digital care record for benchmarking to support improvement projects. C) Realtime analysis of digital care records to identify deterioration and deliver proactive care. Our partnership is working with the software providers to develop these projects to improve continuity of proactive care and to develop indicators to assess outcomes of improvement projects.

Conclusion

Our living labs partnership has enabled care home teams to reflect on their use of digital care records and how these mediate communication within the care team as well as with family carers and primary care colleagues. Fresh perspectives have emerged which may accelerate the impact of digitalisation of care homes.

Introduction

People recently diagnosed with Parkinson’s disease (PD) may withdraw from physical activity because of PD symptoms or loss of confidence. We are conducting a feasibility trial of a remote physiotherapy intervention. To gain a broader understanding of attitudes to physical activity and physiotherapy, we surveyed people with early PD in UK.

Methods

We developed a questionnaire (JISC Online Surveys) about physical activity and remote physiotherapy. This was distributed on paper to local Parkinson’s UK groups, and online via Parkinson’s UK newsletter and social media. 

Results

We received 274 valid responses. The most frequent age category was 60-69 years (69%), and just over half of respondents were male (53%). Respondents of diverse ethnicities amounted to 2% of the total sample. For physical activity, the majority of participants reported a high or average level of physical activity, with only 11% reporting a low level. The majority of participants reported that regular exercise was extremely or very important for keeping well with PD. When asked about barriers to being active, the most common response was apathy (29%), followed by difficulties due to PD symptoms and feeling exhausted. These barriers may be amenable to physiotherapy intervention, and we asked participants about their experience of physiotherapy. 47% reported that they had never had physiotherapy for PD; the remainder ranged from single assessment to more than one course of physiotherapy. In terms of telemedicine, 36% reported having a videoconsultation with a doctor or therapist in the last year, with the majority of these participants reporting a good experience; whereas 7% reported concerns with technology.

Discussion

The majority of respondents were enthusiastic about physical activity and believed this was helpful for their wellbeing. Barriers to exercise may be amenable to physiotherapy intervention. Digital monitoring and telemedicine were acceptable to many respondents.

Background: The MDTea is a free open access medical education podcast designed for all healthcare professionals caring for older adults. To date there are 120 episodes.

Introduction/Method: The MDTea Podcast has CPD survey logs on its website where listeners who access the website can record their learning and receive a CPD certificate, Listeners provide their professional roles. Listener numbers for episodes were much higher than those recorded in the CPD log, so alternative measures were sought to understand who listens to the podcast. Series 11 was released in January to July 2022 and was themed around ‘A Day in the Life’ of health professionals working with older adults in the hospital environment. The MDTea Podcast Twitter account had 6333 followers before series 11 release and has good discussion and engagement with followers, and is regularly tagged in other geriatrics care from discussion by professionals. Measuring the followership and social network of the account may be useful to understand the MDTea’s place in the social network of UK care of older adults healthcare. Therefore with each episode release the new follower numbers and if available self identified professional roles of each were recorded and counted.

Results: Over the course of the 11th series, the MDTea Podcast twitter account gained 432 new followers, from 22 different self defined professional groups who engaged with our social media.121 followers did not identify their title. In contrast 12 self identified professions were recorded in our series 11 CPD log results from 30 responses.

Conclusion: This work has demonstrated the wide range of professionals that engage with FOAMed resources produced by the MDTea. Given the breadth of professionals working in elderly care roles in both primary and secondary settings, having an understanding content users can enable authors to design content that is appropriate for their audience.

Can use of sensor technology prevent hospitalisations in frail older people at high risk of hospital admissions?

Background

There has been significant developments, investment and ambition to use modern technology in admission avoidance in hospitals. Sensor technology has been one area of development. We used My Sense to improve outcomes for a cohort of High Intensity Users (HIU) frail older patients, and compared hospitalisation rates before and after employing Sensor technology. HIU patient consent criteria is 3 Admissions with 40 days Length of Stay.

Introduction

MySENSE

• 8 Sensors placed around the home
• Chargeable wrist device
• Monitors - activity, heart rate, environment temperature

Aim

• To detect change in health and routine
• Reduce deterioration in physical and mental health well-being
• Promote independence
• Unnecessary Admissions

Methods

 Fifty randomly selected HIU patients consented to use My Sense from November 2021 to June 2022.  HIU monitors usage via a dashboard with the aim to intervene and reduce the likelihood of deterioration caused by inactivity or illness.  HIU contacts the key responders, include liaising with family members, GP, other health/care professionals if unusual patterns or no activity is recorded. For example - bed/chair/toilet/kettle/tap sensor not being activated for some time. Indicators for potential UTI’s, constipation, dehydration, reduced mobility and other conditions if not addressed may result in admission.

Results

• Admissions prior to installation 84 post 54
• Length of Stay prior to installation 909 post 724
• Cost saving = £64,750.00
• Cost of equipment £399 with a monthly subscription fees £39.99 per month

Conclusion

• Useful to detect any changes to normal pattern improving patient safety
• Early identification of deterioration and early deployment of help for earlier intervention
• Raised patient, family and staff satisfaction/reassurance
• Reduced reliance on acute care
• Reduced level of physical social care support / greater independence
• Useful tool but more detailed studies are needed.

Introduction. Older people with frailty are at risk of adverse outcomes from hospital admission. Early identification of frailty at can help reduce these. The Clinical Frailty Scale (CFS) identifies frailty, is quick to perform and can be done in acute settings. We have a well-established a Frailty Assessment Unit (FAU) which supports comprehensive geriatric assessment (CGA) for older adults with frailty in hospital. We developed direct admission pathway for frail patients direct from our emergency department (ED) to FAU and we needed to ensure that CFS was performed in the ED. Methods. A training and education programme in CFS was delivered to ED via Frailty nurse practitioners. CFS was embedded in the ED safety briefs and daily handovers. A Frailty link nurse was identified in ED . We implemented an electronic CFS Frailty Alert (eFA) to our electronic Patient Management System. Results. A direct admission pathway was established in March 2021 and eFA began in September 2021 (delayed due to Covid-19) The number of patients presenting to ED who have eFA added at admission has increased from 4/ month to 100/month ( fig1) . This has allowed us to maintain 80% of patients being admitted to FAU ( and therefore to GCA) < 24 hours of attendance at hospital (fig 2). The number of patients who have a eFA recorded in the overall service has also increased (fig3) Fig 1. Fig 2. Fig 3. Conclusion We improved the number of patients with an eFA in ED and can better identify who needs CGA. We can use eFA as a visual tool for site awareness of frailty which helps to support flow. Capability of ED /hospital teams to add eFA was increased and extended to Hospital@Home/ community teams. Finally, this has been shared across our NHSL sites