Why was this study needed?
Why was this study needed?
In the UK, older people account for almost two thirds (65 per cent) of people admitted to hospital. Frail older people make up 30 per cent of acute medical unit inpatients. Frailty and sarcopenia (loss of skeletal muscle mass and strength) are ageing syndromes that can lead to longer hospital stays and increased hospitalisation costs. Poor health outcomes are also common, for instance with frailty-related falls costing the NHS an estimated £4.6 million per day.
Low grip strength is a common indicator of frailty but is not usually assessed in hospital inpatient settings. The routine measurement of grip strength using a relatively low-cost piece of equipment, a dynamometer, could help identify at-risk older inpatients. It could also support the implementation of appropriate early healthcare interventions to prevent poor health outcomes and speed up the discharge process.
This study assessed the feasibility and acceptability of a strategy to implement grip strength measurement into routine clinical practice in inpatient settings for older people.
What did this study do?
This mixed-methods study was conducted within one hospital in England across five acute medical wards. Grip strength training on using a Jamar dynamometer was provided to 155 staff, mainly nurses. Training and ward visits were provided by the research team throughout the nine-month implementation period.
Staff were instructed to use the grip strength test on all patients over 80 years of age. If they had low grip strength, staff were directed to set up a dietary assessment and refer them to physiotherapy to consider resistance training exercises.
Semi-structured interviews and focus groups were carried out with 15 clinical staff members and eight patients on the acceptability of the test.
As a feasibility study, this is early research designed to understand the practical issues in using the grip test and to uncover any limitations to implementing it in other settings with different organisational cultures or structures.
What did it find?
- Grip strength was measured in 811/2,043 (40 per cent) eligible people. Looking at a sample of 86 people with low grip strength, nutritional supplements were prescribed to 60 per cent of them and strength exercises to 20 per cent. High levels of acceptance were found in the eight patients interviewed. Most found no difficulty in doing the grip strength test.
- Training sessions lasted around 20 minutes and were not considered disruptive to daily working practices. High levels of confidence in measuring grip strength and using the care plan were reported by staff in a post-training evaluation.
- Acceptance of the intervention by staff was variable across wards. Supportive ward managers and keen ward champions achieved better implementation and staff acceptance. Regular changes in ward managers, lack of interest, and lack of support for the intervention were barriers to acceptance and implementation.
- Dieticians thought that it could be useful for early identification of people who could benefit from supplements, but also expressed some reservations about inappropriate prescribing.
- The costs reported for delivering training across all five wards were between £2,218 and £2,302 per year and between £5.78 and £10 per patient, depending on the seniority of staff. Dietician and physiotherapy costs were not included.
What are the implications?
Incorporating grip strength measurement into routine assessment is potentially a more consistent approach to identifying patients at risk of frailty.
This study indicates mostly positive attitudes among staff and patients towards routine measurement of grip strength in an acute hospital inpatient setting. Routine implementation is feasible; however, success would depend on a strong investment of time, willingness to engage, and commitment from all staff involved. The use of ward champions seemed important for success. This might be difficult in wards with high staff turnover. This study was based on one hospital only, so results may not be generalisable to all other sites.
Routine implementation appears low cost, but any workload implications for physiotherapists and dieticians could be considered further before this test becomes widespread.
Citation and funding
Ibrahim K, May C, Patel H, et al. Implementation of grip strength measurement in medicine for older people wards as part of routine admission assessment: identifying facilitators and barriers using a theory-led intervention. BMC Geriatrics. 2018;18(1):79.
This study was funded by the NIHR Collaboration for Leadership in Applied Health Research and Care Wessex. The full NIHR Signal and additional expert commentary was published on 2 October 2018.
Commentary by Dr Vicky Booth
Originally linked to aging, frailty refers to an individual whom we recognise as vulnerable and who is having a dip in their ability to cope with everyday stressors and strains. It is a long-term condition that we are getting better at identifying.
This study by Ibrahim goes beyond just highlighting the simple use of grip strength as an outcome measure. It demonstrates the premise that if we can identify frailty more accurately and consistently, then we can shift how we treat these patients, moving from a reactive to a proactive approach. But are we routinely using this measure in clinical practice?
Physiotherapists are ideally placed to identify and intervene in frailty, however, recognising it should not be the domain of just one health professional. Ibrahim found that a team approach was more likely to be successful, using champions and ward managers to take the lead in making measuring grip strength part of everyday practice. Like any new approach, it takes time and effort to be adopted. We all know the strains and stressors in today’s NHS. However, the rewards for using this type of simple measure are potentially exponential. Could something so simple really help shift how we approach our frail patients?
- Dr Vicky Booth (AHP Clinical Academic Lead, Nottingham University Hospitals NHS Trust)
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