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Background: Older people are among the most vulnerable patients in acute care hospitals. The hospitalisation process can result in newly acquired functional or cognitive deficits termed hospital associated decline (HAD). Prioritising fundamental care including mobilisation, nutrition, and cognitive engagement can reduce HAD risk. Aim: The Frailty Care Bundle (FCB) intervention aims to implement and evaluate evidence-based principles on early mobilisation, enhanced nutrition and increased cognitive engagement to prevent functional decline and HAD in older patients. Methods: A hybrid implementation science study will use a pragmatic prospective cohort design with a pre-post mixed methods evaluation to test the effect of the FCB on patient, staff, and health service outcomes. The evaluation will include a description of the implementation process, intervention adaptations, and economic costs analysis. The protocol follows the Standards for Reporting Implementation Studies (StaRI). The intervention design and implementation strategy will utilise the behaviour change theory COM-B (capability, motivation, opportunity) and the Promoting Action on Research Implementation in Health Services (i-PARIHS). A clinical facilitator will use a co-production approach with staff. All patients will receive care as normal, the intervention is delivered at ward level and focuses on nurses and health care assistants (HCA) normative clinical practices. The intervention will be delivered in three hospitals on six wards including rehabilitation, acute trauma, medical and older adult wards. Evaluation: The evaluation will recruit a volunteer sample of 180 patients aged 65 years or older (pre 90; post 90 patients). The primary outcomes are measures of functional status (modified Barthel Index (MBI)) and mobilisation measured as average daily step count using accelerometers. Process data will include ward activity mapping, staff surveys and interviews and an economic cost-impact analysis. Conclusions: This is a complex intervention that involves ward and system level changes and has the potential to improve outcomes for older patients.

Additional file 2: Appendix 2. Deviations from the published protocol.

Additional file 1: Appendix 1. Description of APEP and Sham Exercise Programmes.

The aim of this thesis was to measure the effectiveness of additional exercises on length of stay, physical performance and quality of life for frail older medical inpatients. The thesis, in three phases (1) identified a suitable and accurate motion sensor to measure walking in hospital, (2) measured walking in hospital, and (3) measured the effectiveness of an augmented prescribed exercise programme (APEP) for frail older acute medical (RCT). Phase 1: A scholarly review identified two accelerometers and three pedometers showing potential, and a validation study (n=32), identified one of these as suitably accurate. Phase 2: The accelerometer was used to measure the association between walking (step-count) and (1) length of stay, (2) physical performance and (3) potential influencers of walking (n=154). More walking (50%) was associated with a 6% shorter hospital stay. Better physical performance on admission predicted 15% more walking, and assigned bed-rest and tethering treatments were associated with less walking (70% and 30% respectively). Phase 3: The effectiveness of the APEP was measured (n=190), using length of stay as the primary outcome measure. Twice-daily exercise sessions were delivered; strengthening/balance to the intervention group, stretching/relaxation to the control group. Many (35%) patients were transferred to sub-acute care. A 30% shorter length of stay (patients discharged directly home only), was detected, however, failed to reach significant significance (n=128), (HR 1.3 (CI 0.90-1.87) p=0.1). Improved physical performance at discharge (β 0.88 (CI 0.2-1.57) p=0.01), quality of life at follow-up (β 0.28 (CI 0.91-0.47) p=0.004) and less negative events (pooled falls, prolonged hospital stays, deaths and long-term care admissions) (OR 0.42 (0.2-0.92) p=0.03, post hoc analysis) were detected. The results indicate that older inpatients’ inactivity is associated with length of stay. Additional exercises improved physical performance and quality of life. Its effect on length of stay remains inconclusive.

Objectives: To measure the step-count accuracy of an ankle-worn accelerometer, a thigh-worn accelerometer and one pedometer in older and frail inpatients. Design: Cross-sectional design study. Setting: Research room within a hospital. Participants: Convenience sample of inpatients aged ≥65 years, able to walk 20 metres unassisted, with or without a walking-aid. Intervention: Patients completed a 40-minute programme of predetermined tasks while wearing the three motion sensors simultaneously. Video-recording of the procedure provided the criterion measurement of step-count. Main Outcome Measures: Mean percentage (%) errors were calculated for all tasks, slow versus fast walkers, independent versus walking-aid-users, and over shorter versus longer distances. The Intra-class Correlation was calculated and accuracy was visually displayed by Bland-Altman plots. Results: Thirty-two patients (78.1 ±7.8 years) completed the study. Fifteen were female and 17 used walking-aids. Their median speed was 0.46 m/sec (interquartile range, IQR 0.36-0.66). The ankle-worn accelerometer overestimated steps (median 1% error, IQR -3 to 13). The other motion sensors underestimated steps (40% error (IQR -51 to -35) and 38% (IQR -93 to -27), respectively). The ankle-worn accelerometer proved more accurate over longer distances (3% error, IQR 0 to 9), than shorter distances (10%, IQR -23 to 9). Conclusions: The ankle-worn accelerometer gave the most accurate step-count measurement and was most accurate over longer distances. Neither of the other motion sensors had acceptable margins of error.

Introduction: The older adult population is increasing dramatically. Older adults experience prolonged hospital admissions and are at a higher risk of experiencing hospital-associated decline, with frail older adults being even more vulnerable. This increases their risk of mortality, readmission, and care-dependency. The Integrated Care Programme for Older Persons (ICPOP) was introduced in Ireland in response to these demanding demographic changes, with an aim of improving quality of life for older adults by supporting them to live well in their homes. The framework for the ICPOP places an emphasis on the importance of evaluating the structural, process and patient outcomes in order to achieve the service objectives. This thesis addresses patient outcomes, with an overall aim of exploring patients’ and carers’ experiences and perceptions of the ICPOP in Cork city. The participants’ feedback will be used to further refine the service. Method: In order to approach this research question, it was necessary for the researcher to gain a more in-depth knowledge on the characteristics of similar models of care worldwide, and their effectiveness compared to usual inpatient care. Therefore, this project was divided into two phases. Phase 1 consisted of a systematic review. The main objective of this review was to determine whether hospital at home is an effective model of care for acutely unwell older adults, compared to usual inpatient care. A secondary aim was to further explore the optimal parameters (i.e. frequency, intensity, duration, and type of care provided) in the delivery of care, to improve patient outcomes. The findings of this review were also used to inform the interview schedule which was used in Phase 2. In Phase 2, the researcher addressed the main research question using qualitative research methods. Semi-structured interviews were carried out with patients and carers in their own homes. The interview guide was developed with guidance from the themes, as listed by Proctor et al (2011), exploring implementation, service, and client outcomes. Data was analysed using thematic analysis. The resulting categories were then organised using the constructs of the conceptual framework for implementation outcomes. Results: In phase 1, a total of 917 studies were screened. Among these, 23 studies were identified as highly relevant, with 16 studies ultimately fulfilling the inclusion and exclusion criteria and being included for review. The systematic review was limited by a lack of newly published randomised controlled trials and a high risk of bias across many studies. In the context of these limitations, there was evidence to support hospital at home in the areas of patient and carer satisfaction and carer burden, compared to usual inpatient care. It was not possible to determine optimal parameters in the delivery of care due to the under-reporting of interventions across many of the studies. The qualitative study revealed service users’ overwhelming satisfaction with the ICPOP. Key elements contributing to this included the accelerated discharge from hospital and home-based rehabilitation, caring personnel, the positive, therapeutic relationships developed with staff, reassurance for patients and carers and the patient’s functional recovery. Some uncertainties regarding the duration of care, end of care and rehabilitative element of the service were also highlighted. Conclusion: This study has made an important contribution to the topic of hospital at home models of care for the older adult. This study demonstrated that the patients’ and carers’ satisfaction with this service is largely due to receiving care in the home environment, the social aspect of care, reassurance for both the patient and carer, and the patients’ functional recovery. The importance of continuity of care and social relationships was also highlighted. Further high quality RCTs are necessary in order to determine the effectiveness of hospital at home care compared to usual inpatient care for the older adult, with accurate reporting of interventions in order to explore the optimal characteristics for the delivery of this model of care to improve patient outcomes.