Improving the Rehabilitation Experience for Older People and Staff

The experience of caring for an older relative in rehabilitation has inspired a Queensland physician to explore how her research into improving acute hospital care for older patients can be applied in a rehabilitation setting.

The experience of caring for an older relative in rehabilitation has inspired a Queensland physician to explore how her research into improving acute hospital care for older patients can be applied in a rehabilitation setting.

“My Auntie Carmel developed delirium while in hospital after fracturing her leg. Delirium is one of the most common hospital-acquired complications in older people, and it was still there when she moved into rehabilitation,” said Professor Alison Mudge from Metro North Hospital and Health Service and The University of Queensland.

While inpatient rehabilitation often focuses on restoring physical function and independence, recent studies highlight that cognitive impairment (due to delirium, dementia or acquired brain injury, such as stroke) is present in about two-thirds of Australian rehabilitation inpatients. This impairment can hamper their recovery, perhaps because it is not always recognised and managed well.

Professor Alison Mudge (left) with her Auntie Carmel

“Delirium is acute confusion that can develop as a result of an illness, injury, operation or medication, and makes it hard to make sense of the world,” said Professor Mudge.

“Carmel was very upset and scared of the staff and struggled to understand any complex instructions. The nurses and therapists were frustrated because she didn’t do as she was told. It was a terrible experience for everyone.”

In 2011, Professor Mudge and her team developed an evidence-based care model called Eat Walk Engage. The program aimed to prevent delirium and support the recovery of older patients in acute care settings. The Royal Brisbane and Women’s Hospital was the first hospital to test Eat Walk Engage, and there the team showed it was an effective integrated model of care.

“Next, we ran a large trial across four Queensland hospitals. The trial showed an almost 50 per cent reduction in delirium, and other benefits including shorter hospital stays and less need for rehabilitation stays,” Professor Mudge said.

The team’s findings informed the Frail Older Person’s Collaborative Program, a $30 million per year investment by Queensland Health. As a result, Eat Walk Engage is now in routine use in 20 hospitals across Queensland, along with other initiatives that support better care of older people.

But Professor Mudge identified a gap – the implementation of these initiatives into rehabilitation units. So she successfully applied for a Rapid Applied Research Translation (RART) grant from the Medical Research Future Fund.

The RART project is testing the feasibility of the acute care model in a rehabilitation setting, and enhances the model through a cross-institutional collaboration with Professor Elizabeth Beattie and her team from the Queensland University of Technology and Dementia Training Australia.

Professor Beattie had previously developed an online training program about cognitive impairment called The View From Here. The program helps healthcare professionals recognise cognitive impairment, understand the care experience from the patient’s viewpoint, and adapt their care to be more person-centred.

In 2020, the RART project team tested their combined model in Redcliffe Hospital’s rehabilitation unit. Nursing staff received protected time during their work hours to complete the education component. An Eat Walk Engage facilitator also supported care teams to listen to patient perspectives, develop some shared improvement goals, and design and test improvements.

“For example, a wall of pet photographs provided somewhere for patients to walk to and use as a great conversation starter,” Professor Mudge said. “Purchasing puzzles, DVD players and craft materials provided patients with meaningful activities. Making an inviting lounge area for patients and families encouraged more visitors. We also had a trained clinical assistant who supported patients to stay more physically and mentally active.

Professor Mudge says that despite the disruptions of the COVID-19 pandemic, the study has shown promising results.

“Nursing staff reported greater confidence in managing dementia and delirium. Audits showed improvements in providing the fundamentals of care that are so important to prevent complications like delirium and help patients recover faster,” Professor Mudge said.

Staff commented that they saw more ‘moments of joy’ among their patients and that staff recognition and management of delirium was much better. Although some staff were initially worried the program would take too much time, they were relieved to get the support to improve things slowly and systematically as a team.

Patients appreciated the additional assistance they received from the Eat Walk Engage assistant and nursing staff. The extra resources and environmental changes also made it easier to stay physically and mentally active on the ward.

“In a similar way to acute care, our initial research has shown that you can improve the processes of care by improving knowledge about how to care for older people, empowering local health leaders and getting teams working together well,” said Professor Mudge.

She says the initial trial in the rehabilitation ward showed promising outcomes, including faster recovery and more likelihood of discharge home. However, the findings are preliminary, and the program needs further testing. 

“After seeing that it is feasible, acceptable and effective in the one rehabilitation setting, the next logical step is to test the effectiveness and cost of this combined program across several sites,” Professor Mudge said. “We’re looking to collaborate with research teams in other jurisdictions to make this happen.”

The project team:

  • Professor Alison Mudge, (lead) Metro North Hospital and Health Service (HHS) and School of Clinical Medicine, The University of Queensland (UQ)
  • Professor Elizabeth Beattie, QUT Faculty of Health School of Nursing
  • Professor Len Gray, UQ Faculty of Medicine Centre for Research in Geriatric Medicine
  • Professor Ruth Hubbard, UQ Faculty of Medicine Centre for Research in Geriatric Medicine
  • Ms Prue McRae, Metro North HHS (RBWH)
  • Dr Catherine Yelland, Metro North HHS (Redcliffe Hospital)
  • Dr Amanda Fox, Metro North HHS (Redcliffe Hospital)
  • Ms Sandra Jeavons, QUT Faculty of Health School of Nursing

Useful links:

Eat Walk Engage

Frail Older Person’s Collaborative Program

The View From Here

Australian Journal of Dementia Care

Rapid Applied Research Translation initiative

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