Implementation of a Frailty Care Bundle (FCB) to reduce hospital associated decline in older orthopaedic trauma patients: pretest-posttest intervention study
BackgroundHospital associated decline (HAD) in older patients is an under-recognised and under-treated hospital harm. Fundamental care prioritising mobilisation, nutrition and cognitive well-being is protective against HAD, but it is inconsistently priortised in busy clinical settings. ObjectiveThe study aimed to implement and evaluate a frailty care bundle (FCB) for orthopaedic trauma patients in acute and rehabilitation settings to increase mobilisation, nutrition and cognitive well-being to reduce HAD. The intervention was delivered during the COVID-19 pandemic. DesignThe implementation science study used a step wedge pre-post design with multi-methods evaluation. Setting: Four wards across two hospitals: two acute trauma orthopaedic wards (n=62 beds) and two orthopaedic rehabilitation wards (n=33 beds). Participants: We enrolled 120 participants (pre n=60 and post n=60 implementation of the FCB across sites and wards), and at post-discharge follow-up there were 74 participants (pre n=43, post n=36).MethodsThe intervention implementation was underpinned by behaviour change theory COM-B and Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS). All wards received the intervention. A clinical facilitator worked with ward teams to prioritise and implement changes. The main changes were: setting a daily patient mobility goal, promoting assisted meal times, additional snacks, provision of distraction resources, and communication. Implementation strategies included establishing a multdisciplinary team local implementation group, staff education, audit and feedback, coaching, and role modelling. The main outcomes were participants' return to pre-trauma baseline functional capability at 6-8 weeks post-hospital discharge measured using the modified Bartels Index (mBI) and median hospital step count measured using accelerometers. Descriptive statistics included medians, interquartile ranges (IQR), proportions and percentages. Pre versus post group differences were estimated using log-linear models for step count and ordinal regression models for mBI and other outcomes. Odds ratios (OR) and 95% confidence intervals (CI) are reported. ResultsParticipants median age was 78 years, 83% were female and the post intervention group tended to be more frail. During hospitalisation, accelerometer data indicated a non-significant 11% (OR 1.11 95% 0.72-1.7) increase in post-intervention step count compared to pre. Post-intervention participants were more likely than pre-intervention participants to report higher post-discharge mBI scores relative to pre-admission scores OR 2.29( 95% CI 0.98-5.36), but it was not statistically significant (p=0.056). ConclusionIt was feasible to implement aspects of the FCB that ward teams had influence over, but system barriers persisted in addition to COVID-19 challenges. The changes remain tentative and require ongoing facilitation and monitoring for sustainability. Improved consistency in fundamental care, especially mobilisation may accelerate functional recovery<br/