Inter-rater reliability of care home staff's proxy judgements with residents' assessments of their own health-related quality of life: an analysis of the PATCH trial EQ-5D data.

OBJECTIVES: to compare care staff proxies with care home residents' self-assessment of their health-related quality of life (HRQoL). METHODS: we assessed the degree of inter-rater reliability between residents and care staff proxies for the EQ-5D-5L index, domains and EQ Visual Analogue Scale at baseline, 3 months and 6 months, collected as part of the PATCH trial. We calculated kappa scores. Interpreted as <0 no agreement, 0-0.2 slight, 0.21-0.60 fair to moderate and >0.6 substantial to almost perfect agreement. Qualitative interviews with care staff and researchers explored the challenges of completing these questions. RESULTS: over 50% of the HRQoL data from residents was missing at baseline compared with a 100% completion rate by care staff proxies. A fair-to-moderate level of agreement was found for the EQ-5D-5L index. A higher level of agreement was achieved for the EQ-5D-5L domains of mobility and pain. Resident 'non-completers' were more likely to: be older, have stayed a longer duration in the care home, have lower Barthel Index and Physical Activity and Mobility in Residential Care (PAM-RC) scores, a greater number of co-morbidities and have joined the trial through consultee agreement. Interviews with staff and researchers indicated that it was easier to rate residents' mobility levels than other domains, but in general it was difficult to obtain data from residents or to make an accurate proxy judgement for those with dementia. CONCLUSIONS: whilst assessing HRQoL by care staff proxy completion provides a more complete dataset, uncertainty remains as to how representative these values are for different groups of residents within care homes.

A posture and mobility training package for care home staff: results of a cluster randomised controlled feasibility trial (the PATCH trial).

BACKGROUND: provision of care for care home residents with complex needs is challenging. Physiotherapy and activity interventions can improve well-being but are often time-limited and resource intensive. A sustainable approach is to enhance the confidence and skills of staff who provide care. This trial assessed the feasibility of undertaking a definitive evaluation of a posture and mobility training programme for care staff. DESIGN AND SETTING: a cluster randomised controlled feasibility trial with embedded process evaluation. Ten care homes in Yorkshire, United Kingdom, were randomised (1:1) to the skilful care training package (SCTP) or usual care (UC). PARTICIPANTS: residents who were not independently mobile. INTERVENTION: SCTP-delivered by physiotherapists to care staff. OBJECTIVES AND MEASUREMENTS: key objectives informed progression to a definitive trial. Recruitment, retention and intervention uptake were monitored. Data, collected by a blinded researcher, included pain, posture, mobility, hospitalisations and falls. This informed data collection feasibility and participant safety. RESULTS: a total of 348 residents were screened; 146 were registered (71 UC, 75 SCTP). Forty two were lost by 6 months, largely due to deaths. While data collection from proxy informants was good (>95% expected data), attrition meant that data completion rates did not meet target. Data collection from residents was poor due to high levels of dementia. Intervention uptake was variable-staff attendance at all sessions ranged from 12.5 to 65.8%. There were no safety concerns. CONCLUSION: care home and resident recruitment are feasible, but refinement of data collection approaches and intervention delivery are needed for this trial and care home research more widely.

PATCH: posture and mobility training for care staff versus usual care in care homes: study protocol for a randomised controlled trial.

BACKGROUND: Residents of care homes have high levels of disability and poor mobility, but the promotion of health and wellbeing within care homes is poorly realised. Residents spend the majority of their time sedentary which leads to increased dependency and, coupled with poor postural management, can have many adverse outcomes including pressure sores, pain and reduced social interaction. The intervention being tested in this project (the Skilful Care Training Package) aims to increase the awareness and skills of care staff in relation to poor posture in the older, less mobile adult and highlight the benefits of activity, and how to skilfully assist activity, in this group to enable mobility and reduce falls risk. Feasibility work will be undertaken to inform the design of a definitive cluster randomised controlled trial. METHODS: This is a cluster randomised controlled feasibility trial, aiming to recruit at least 12-15 residents at each of 10 care homes across Yorkshire. Care homes will be randomly allocated on a 1:1 basis to receive either the Skilful Care Training Package alongside usual care or to continue to provide usual care alone. Assessments will be undertaken by blinded researchers with participating residents at baseline (before care home randomisation) and at three and six months post randomisation. Data relating to changes in physical activity, mobility, posture, mood and quality of life will be collected. Data at the level of the home will also be collected and will include staff experience of care and changes in the numbers and types of adverse events residents experience (for example, hospital admissions, falls). Details of NHS service usage will be collected to inform the economic analysis. An embedded process evaluation will explore intervention delivery and its acceptability to staff and residents. DISCUSSION: Participant uptake, engagement and retention are key feasibility outcomes. Exploration of barriers and facilitators to intervention delivery will inform intervention optimisation. Study results will inform progression to a definitive trial and add to the body of evidence for good practice in care home research. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN50080330 . Registered on 27 March 2017.

Can a multi-factorial assessment and interventional programme decrease inpatient falls in an elderly care ward?

Each year approximately 282,000 inpatient falls are reported to the National Patient Safety Agency (NPSA). A significant number result in death, or moderate to severe injury. (1) Research shows that falls may be reduced by 18 to 31% through multi-factorial assessments and interventions. (4) If a fall cannot be prevented, the patient should receive a prompt and effective response to achieve the best possible recovery and avoidance of further falls. Using 'Plan-Do-Study-Act' learning cycles, our aims were to decrease the inpatient falls rate in an Elderly Care ward by 20% and to improve post-fall care. A baseline audit reviewed incident report forms to establish the number of falls per 1000 patient bed days for one calendar year; the baseline falls rate was 14.70 falls per 1000 bed days between November 2010 and October 2011. A care plan to highlight at-risk patients and allow adaptation of care, a 'walking-stick' incentive poster to encourage nursing staff, and post-fall guidelines, were introduced. Feedback sessions with ward staff and a re-audit were organised subsequent to each intervention. Completion of the care plan was monitored to improve compliance. A re-audit at one year was conducted to assess impact. Feedback was positive regarding the interventions. Monthly monitoring of care plans achieved a compliance rate of 89% and highlighted up to 81% of patients were considered high-risk. The inpatient falls rate, re-audited at one year, was 12.44 falls / 1000 patient bed days, November 2011 to October 2012; a 15.4% reduction. This study demonstrates a 15.4% reduction in falls through use of a multi-factorial assessment and care plan and an incentive poster. As we are yet to obtain our initial goal of 20%, implementation and re-audit is ongoing.