Abstract
BackgroundLow grip strength in older inpatients is associated with poor healthcare outcomes including longer length of stay and mortality. Measuring grip strength is simple and inexpensive. However, it is not routinely used in clinical practice. We aimed to evaluate the implementation of grip strength measurement into routine clinical practice.MethodsThis implementation study was a mixed methods study based in five acute medical wards for older people in one UK hospital. Intervention design and implementation evaluation were based on Normalization Process Theory (NPT). A training program was developed and delivered to enable staff to measure grip strength and use a care plan for patients with low grip strength. Routine implementation and monitoring was assessed using the “implementation outcome variables” proposed by WHO: adoption, coverage, acceptability, fidelity, and costs analysis. Enablers and barriers of implementation were identified.ResultsOne hundred fifty-five nursing staff were trained, 63% in just 3 weeks. Adoption and monthly coverage of grip strength measurement varied between 25 and 80% patients across wards. 81% of female patients and 75% of male patients assessed had low grip strength (< 27 kg for men and < 16 kg for women). Staff and patients found grip measurement easy, cheap and potentially beneficial in identifying high-risk patients. The total cost of implementation across five wards over 12 months was less than £2302. Using NPT, interviews identified enablers and barriers. Enablers included: highly motivated ward champions, managerial support, engagement strategies, shared commitment, and integration into staff and ward daily routines. Barriers included lack of managerial and staff support, and high turnover of staff, managers and champions.ConclusionsTraining a large number of nurses to routinely implement grip strength measurement of older patients was feasible, acceptable and inexpensive. Champions’ motivation, managerial support, and shared staff commitment were important for the uptake and normalisation of grip strength measurement. A high percentage of older patients were identified to be at risk of poor healthcare outcomes and would benefit from nutritional and exercise interventions. Measuring grip strength in these patients could provide an opportunity to identify those with normal grip strength for fast tracking through admission to discharge thereby reducing length of stay.Trial registrationClinicaltrials.gov NCTO2447445. Registered May 18, 2015.
Highlights
Low grip strength in older inpatients is associated with poor healthcare outcomes including longer length of stay and mortality
Measuring grip strength in this group of older patients could provide the opportunity to identify those with normal grip strength and fast track them through admission to discharge
The Normalization Process Theory (NPT) offered a framework for identifying specific factors that enabled implementation, as well as areas to target for future research
Summary
Low grip strength in older inpatients is associated with poor healthcare outcomes including longer length of stay and mortality. Measuring grip strength is simple and inexpensive It is not routinely used in clinical practice. People over 65 years old make up nearly two thirds (65%) of people admitted to hospital in the UK [1, 2] Many of these patients have multiple medical problems including frailty and sarcopenia. Poor healthcare outcomes including increased risk of falls [9], morbidity [10], death [11], longer length of hospital stay and higher hospitalization costs [12,13,14] are all associated with low grip strength among older patients. Progressive resistance training with nutritional intervention has been reported to be feasible, safe and effective for improving muscle strength and treating frailty and sarcopenia [17,18,19,20,21]
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