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TheEDDMpodcast

Educating multidisciplinary health care staff and students to prevent hospital acquired deconditioning by embedding #EatDrinkDressMove into routine care provision.

TheEDDMpodcast © 2024 by Jacqui Holmes is licensed under Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International. To view a copy of this license, visit ttps://creativecommons.org/licenses/by-nc-nd/4.0/

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S1E1 - What is EDDM?

In this first episode of the #theEDDMpodcast, I speak about hospital acquired deconditioning and what EDDM is, how I've re-branded and re-launched EDDM, and the importance of making it everybody's business. With each episode we will also have time for shout outs, pledges and examples of best practice so make sure you post yours on social media with #EDDM and #theEDDMpodcast! And we always finish off by mobilising our minds in the EDDM brainteasers - an opportunity for you to win a sought after EDDM badge!

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Key facts:

  • Hospital acquired deconditioning (HAD) - a loss of independence in activities of daily living (ADL) following acute hospitalisation.

  • Deconditioning syndrome - the condition of physical, psychological and functional decline that occurs as a result of complex physiological changes induced by prolonged bed rest and associated loss of muscle strength (4).

  • Acute medical and surgical patients in hospital spend >90% of their time sedentary, often completing less than 1000 steps a day (2).  

  • 10 days of bed rest can lead to 10 years of muscle ageing in adults over 80 years old (3).

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Resources:

  1. Moving Medicine ⁠https://movingmedicine.ac.uk/consultation-guides/condition/adult/hospital-associated-deconditioning-2/five_minute/⁠

  2. Behaviour change interventions to increase physical activity in hospitalised patients: a systematic review, meta-analysis and meta-regression ⁠https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8753032/pdf/afab154.pdf⁠

  3. NHSE Blog - Dr Amit Arora ⁠https://www.england.nhs.uk/blog/amit-arora/⁠

  4. NHSE Blog – ReconditionTheNation ⁠https://www.england.nhs.uk/blog/recondition-the-nation/⁠

  5. BGS ‘Sit Up, Get Dressed, Keep Moving!’⁠ https://www.bgs.org.uk/policy-and-media/%E2%80%98sit-up-get-dressed-and-keep-moving%E2%80%99⁠

  6. WHO Patient Safey and Preventable Harm ⁠https://www.who.int/news-room/fact-sheets/detail/patient-safety#:~:text=Patient%20safety%20is%20defined%20as,care%20to%20an%20acceptable%20minimum.%22

S1E2 - The Gastrointestinal System

In this episode of the #theEDDMpodcast, I speak about the physical and psychological impact of hospital acquired deconditioning on the gastrointestinal tract, the links between a sedentary lifestyle and gastrointestinal disorders, and how EDDM principles can help. With each episode we will also have time for shout outs, pledges and examples of best practice so make sure you post yours on social media with the #EDDM and #theEDDMpodcast! And we always finish off by mobilising our minds in the EDDM brainteasers - an opportunity for you to win a sought after EDDM badge!

 

Key facts:

  • It is estimated that at least one-third of patients in developed countries are malnourished upon admission to the hospital, and, if left untreated, approximately two-thirds of those patients will experience a further decline in their nutrition status during inpatient stay (1).

  • For patients who are not malnourished upon admission, approximately one-third may become malnourished while in the hospital (1).

  • In one study, one fifth of hospitalized patients 65 years and older had an average nutrient intake of less than 50% of their calculated maintenance energy requirements (2).

  • A 10% loss of Lean Body Mass (LBM) results in immune suppression and increases the risk of infection, and a loss of more than 15%–20% of total LBM will impair wound healing. A loss of 30% or more LBM leads to the development of spontaneous wounds such as pressure ulcers, an increased risk of pneumonia, and a complete lack of wound healing (3).

  • Studies have shown that passage of food is 66% slower in recumbent positions compared to when a person is upright (4).

 

Resources:

  1. Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition https://www.sciencedirect.com/science/article/pii/S2212267213006412

  2. Post-Hospital Syndrome – A Condition of Generalized Risk https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3688067/#:~:text=In%20one%20study%2C%20one%20fifth,not%20fed%20by%20alternate%20means.

  3. Nutrition, anabolism and the wound healing process: An overview https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2642618/

  4. Nursing Times – Effects of bedrest 3: gastrointestinal, endocrine and nervous system https://www.nursingtimes.net/clinical-archive/gastroenterology/effects-of-bedrest-3-gastrointestinal-endocrine-and-nervous-systems-21-01-2019/

  5. Inflammation, Appetite and Food Intake in Older Hospitalized Patients https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6770921/

S1E3 - Dehydration

In this episode of the #theEDDMpodcast, I speak about hospital acquired deconditioning and dehydration, the physical and mental impacts of dehydration, and how EDDM principles can help. With each episode we will also have time for shout outs, pledges and examples of best practice so make sure you post yours on social media with the #EDDM and #theEDDMpodcast! And we always finish off by mobilising our minds in the EDDM brainteasers - an opportunity for you to win a sought after EDDM badge!

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Key facts:

  • Dehydration is a condition caused by abnormal water loss from the body. And it is quantified by a 1% or greater loss of body mass due to fluid loss (1).

  • Water makes up 60% of the human body, and is the primary component of every cell. It is required for chemical reactions, for the distribution of molecules like oxygen and metabolic substrates to cells, it’s involved in the removal of waste products of metabolism and it’s essential for thermoregulation (2).

  • Public Health England (2016) recommends a minimum daily water intake of 1.2 - 2.0 litres (1).

  • 45% of hospital patients will become dehydrated upon admission (1).

  • A UK study found one in every five older people living in long-term care to be dehydrated and half to be either dehydrated or at risk of becoming so (4).

  • Even being dehydration by just 2% can affect memory and focus (5).

  • 25% of all patients who develop hospital acquired dehydration will also develop an AKI (1).

 

Resources:

  1. Prevention of Dehydration in Hospital Patients https://researchonline.ljmu.ac.uk/id/eprint/8869/3/Prevention#:~:text=Dehydration%20is%20quantified%20by%20a,intake%20of%201.2%20%2D%202.0%20litres.

  2. Water intake, water balance, and the elusive daily water requirement https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6315424/

  3. NHS https://www.nhs.uk/live-well/eat-well/food-guidelines-and-food-labels/water-drinks-nutrition/#:~:text=Daily%20fluid%20intake,tea%20and%20coffee%2C%20all%20count.

  4. A multidisciplinary consensus on dehydration: definitions, diagnostic methods and clinical implications https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7877883/#:~:text=The%20problem%20is%20not%20restricted,%2Fkg)%20%5B3%5D.

  5. Cognitive performance and dehydration https://pubmed.ncbi.nlm.nih.gov/22855911/

  6. Effects of hydration status on cognitive performance and mood https://www.cambridge.org/core/journals/british-journal-of-nutrition/article/effects-of-hydration-status-on-cognitive-performance-and-mood/1210B6BE585E03C71A299C52B51B22F7

  7. DBTH But First a Drink https://www.dbth.nhs.uk/news/improving-hydration-patients-local-hospitals/#:~:text=Another%20element%20of%20this%20ongoing,record%20the%20patients%20fluid%20balance.

S1E4 - Psychosocial Function

In this episode of the #theEDDMpodcast, I speak about the impact of hospital acquired deconditioning on psychosocial function including psychological wellbeing, motivation, self efficacy, social connectedness and identity, as well as how EDDM principles can help! With each episode we will also have time for shout outs, pledges and examples of best practice so make sure you post yours on social media with the #EDDM and #theEDDMpodcast! And we always finish off by mobilising our minds in the EDDM brainteasers - an opportunity for you to win a sought after EDDM badge!

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Key facts:

  • A study of hospitalized community‐dwelling older people at 6 months after discharge showed that 43% needed continuing help with medications, 24% were still unable to walk a quarter of a mile, and 45% were still unable to drive (1).

  • An early study noted that 36% of hospitalized older patients had high levels of anxiety and depression; and 1 month after discharge, half of them remained anxious and depressed (1).

  • In response to stressors like this, the body releases the stress hormone cortisol in a process known as allostasis. Prolonged allostasis or allostatic overload can cause further deconditioning and adverse patient outcomes (1).

  • Participants from a qualitative study exploring the lived experiences of deconditioning in hospital in Ontario in Canada, described insufficient activities in hospital leading to boredom and mental and physical deconditioning. Patients were frustrated with experiencing deconditioning and their decline in function seemed to impact their sense of self and identity (2).

 

Resources:

  1. Hospital‐associated deconditioning: Not only physical, but also cognitive https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9303382/

  2. A qualitative study exploring the lived experiences of deconditioning in hospital in Ontario, Canada https://pubmed.ncbi.nlm.nih.gov/33750320/#:~:text=Results%3A%20A%20total%20of%2080,sense%20of%20self%20and%20identity.

  3. Lack of meaningful activity on acute physical hospital wards: Older people’s experiences https://journals.sagepub.com/doi/abs/10.1177/0308022617735047?journalCode=bjod

  4. Donate2Motivate https://www.donate2motivate.co.uk/

S1E5 - The Musculoskeletal System 

In this episode of the #theEDDMpodcast, I speak about the impact of hospital acquired deconditioning on the musculoskeletal system, including bones, joint function, muscle mass and strength, as well as the impact of a sedentary lifestyle on musculoskeletal disorders and how EDDM principles can help! With each episode we will also have time for shout outs, pledges and examples of best practice so make sure you post yours on social media with the #EDDM and #theEDDMpodcast! And we always finish off by mobilising our minds in the EDDM brainteasers - an opportunity for you to win a sought after EDDM badge!

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Key facts:

  • In the United Kingdom, physical inactivity is the fourth greatest cause of ill health with negative impacts on health, social and economic outcomes for individuals and communities. It is responsible for 1 in 6 UK deaths, which is equivalent to smoking (1). Importantly, up to 40% of long-term conditions could be prevented if everyone met the UK Chief Medical Officer’s physical activity recommendations which are:

    • Each week, adults should accumulate at least 150 minutes (2 1/2 hours) of moderate intensity activity

    • or 75 minutes of vigorous intensity activity (such as running); or even shorter durations of very vigorous intensity activity

    • or a combination of moderate, vigorous and very vigorous intensity activity.

    • Children and young people should engage in moderate-to-vigorous intensity physical activity for an average of at least 60 minutes per day across the week

    • Adults and children should aim to minimise the amount of time spent being sedentary, and when physically possible should break up long periods of inactivity with at least light physical activity (2).

  • 27% of the general population are classified as ‘inactive’, meaning they do less than 30 minutes of physical activity (such as walking) per week (1).

  • 33% of children do less than ½ recommended physical activity for their age (1).

  • 50% of the physical decline associated with ageing is actually disuse atrophy from prolonged physical inactivity (3).

  • Older adults spend approximately 83% of their hospital stay in bed and 12% of their time in a chair (4).

  • Acute medical and surgical patients spend over 90% of their time in hospital sedentary often completing less that 1000 steps a day (5).

  • Immobilisation can lead to 3-4% reduction in muscle strength per day during the first week and there is a 40% decrease in isokinetic muscle strength after 3 weeks of immobilisation.

  • In young, healthy adults, there has been shown to be a total body lean mass loss of 2.6 kg following 119 days of bed rest in healthy young males; of this, 2.4 kg was from the legs (0.14 kg·wk-1) (6).

  • A loss of lean body mass by 10% decreases immunity and increases risk of infection, 20% decreases wound healing, increases muscle weakness and increases risk of infection, by 30% difficulty sitting, pressure ulcers, pneumonia, inability to heal. And by 40% increases risk of death, usually from pneumonia (7).

  • Changes to the structure and functioning of tendons, ligaments and cartilage start to become apparent after 4-6 days of immobility and can remain, even after normal activity has been resumed. Most of these changes appear to be due to the altered structure of collagen fibres (8).

  • Bone mass (bone mineral density/BMD) is positively associated with physical activity (9).

  • For adults over 80 years old, 10 days of bed rest can result in 10 years of muscle ageing (10).

  • Sarcopenia increases from 14% in those aged 65 - 70, to 53% in those above 80 years of age (11).

  • Epidemiological evidence indicates higher volumes of sedentary behaviour are associated with several musculoskeletal pain conditions, including osteoarthritis, osteoporosis, back, neck and shoulder pain, hip pain and patellofemoral joint pain (12).

  • 68% of patients with 2 or more long term conditions want to do more activity – 25% of patients would be more active if advised by a healthcare professional. Patients also trust the advice of hospital healthcare professionals: 93% of people trust advice from hospital doctors. 91% of people would accept advice from hospital doctors (1).

  • Systematic reviews have shown that improvement in mobility and balance over the first 48 hrs of admission are associated with prevention of hospital associated deconditioning by maintaining or improving physical functioning, as well as shorter recovery times and reduced length of stay (1).

 

Resources:

  1.  Moving Medicine – Why Moving Matters https://movingmedicine.ac.uk/why-movement-matters/why-moving-matters-2/

  2.  UK Chief Medical Officers' Physical Activity Guidelines https://assets.publishing.service.gov.uk/media/5d839543ed915d52428dc134/uk-chief-medical-officers-physical-activity-guidelines.pdf

  3. The second fifty years: promoting health and preventing disability https://www.ncbi.nlm.nih.gov/books/NBK235601/

  4. NHSE #EndPJParalysis: the revolutionary movement helping frail older people https://www.england.nhs.uk/2018/06/endpjparalysis-revolutionary-movement-helping-frail-older-people/

  5. How much do hospitalized adults move? A systematic review and meta-analysis https://www.researchgate.net/publication/335596257_How_much_do_hospitalized_adults_move_A_systematic_review_and_meta-analysis

  6. Protecting muscle mass and function in older adults during bed rest https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3276215/

  7. Nutrition, Anabolism, and the Wound Healing Process: An Overview https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2642618/

  8. Nursing Times. Effects of bedrest 5: the muscles, joints and mobility https://www.nursingtimes.net/clinical-archive/orthopaedics/effects-of-bedrest-5-the-muscles-joints-and-mobility-18-03-2019/

  9. Correlation between sedentary activity, physical activity and bone mineral density and fat in America: National Health and Nutrition Examination Survey, 2011–2018 https://www.nature.com/articles/s41598-023-35742-z

  10. NHSE Blog. Time to move: Get up, get dressed, keep moving https://www.england.nhs.uk/blog/amit-arora/

  11. Clinical definition of sarcopenia https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4269139/

  12. Musculoskeletal pain and sedentary behaviour in occupational and non-occupational settings: a systematic review with meta-analysis https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8666269/

  13. Move it or Lose it The Cuppa Routine  https://www.moveitorloseit.co.uk/cuppa/

S1E6 - Deconditioning at the front door, with Chris Wood

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In this episode of the #theEDDMpodcast, I’m joined by Chris Wood – a senior physiotherapist working for the older persons assessment and liaison service at the QE hospital in Birmingham - to speak about EDDM as a whole, and the impact of deconditioning at the front door within the emergency department or A&E, and how services like frailty same day emergency care can support patients to be cared for in the right place, to prevent deconditioning. With each episode we will also have time for shout outs, pledges and examples of best practice so make sure you post yours on social media with the #EDDM and #theEDDMpodcast! And we always finish off by mobilising our minds in the EDDM brainteasers - an opportunity for you to win a sought after EDDM badge!

 

Key facts:

  • Clinical Frailty Scale (CFS) or Rockwood score is a well-validated scale that evolved from the Canadian Study of Health and Aging and is frequently used in clinical settings. It provides a summary tool for clinicians to assess frailty and fitness based on their clinical judgment and evaluation of a patient. It was initially created with a scale from 1 (very fit) to 7 (severely frail) upon initial publication in 2005. In 2007, however, the CFS was modified to a 9-point scale to include very severely frail and terminally ill as separate entities. The CFS was updated again in 2020 with clarifying edits to the description and labels of the various levels of frailty. The severity of frailty increases with each numbered level, and there is a visual chart to assist with the frailty classification (1).

  • The CFS should be assessed at ED triage, or any first point of contact with acute care (including by paramedics), alongside Early Warning Scores. It should be reassessed after two weeks if clinically relevant.

  • The Comprehensive Geriatric Assessment (CGA) is a process of care comprising a number of steps. Initially, a multidimensional holistic assessment of an older person considers health and wellbeing and leads to the formulation of a plan to address issues which are of concern to the older person (and their family and carers when relevant). Interventions are then arranged in support of the plan. Progress is reviewed and the original plan reassessed at appropriate intervals with the interventions reconsidered accordingly (2).

  • The NHS Long Term Plan states that all hospitals with a 24 hour A&E will provide an Acute Frailty service for at least 70 hours a week, with the aim to complete a clinical frailty assessment within 30 minutes of a patients arrival in the Emergency Department or SDEC unit (3).

  • Early identification and assessment of frail patients allow services to adapt their vulnerable adults’ care. This identification ensures that patient needs are met by using the SDEC model, to identify those that require hospital admission and/or those whose conditions will be better managed in the community (i.e. via Primary Care and community support) (3).

  • The British Geriatric Society (BGS) sets out five principles that should underpin front door frailty services. It provides tips on establishing services from those who have been through the process (4). 

  • Getting It Right First Time (GIRFT) published a Hospital Acute Care Frailty Pathway in 2023 (5).

  • The British Geriatrics Society (BGS) and Getting It Right First Time (GIRFT) published new guidance aimed at supporting hospital teams to improve care for older people living with frailty (6).

  • NICE guidelines cover assessment of fall risk and interventions to prevent falls in people aged 65 and over. It aims to reduce the risk and incidence of falls and the associated distress, pain, injury, loss of confidence, loss of independence and mortality (7).

  • Social prescribing, also sometimes known as community referral, is a means of enabling health professionals to refer people to a range of local, non-clinical services. The referrals generally, but not exclusively, come from professionals working in primary care settings, for example, GPs or practice nurses (8).

  • A study has found that older adult patients state that the hospital environment is not conducive for promoting ambulation. Being tethered to medical equipment such as intravenous lines, wearing embarrassing gowns, and receiving messages from nursing staff that independent ambulation is not permitted in order to prevent falls, all serve as barriers to patient-initiated ambulation (9).

 

References:

  1. CFS or Rockwood Score https://www.bgs.org.uk/sites/default/files/content/attachment/2018-07-05/rockwood_cfs.pdf

  2. British Geriatric Society (BGS) CGA Toolkit https://www.bgs.org.uk/resources/resource-series/comprehensive-geriatric-assessment-toolkit-for-primary-care-practitioners

  3. NHSE Acute frailty https://www.england.nhs.uk/urgent-emergency-care/same-day-emergency-care/acute-frailty/

  4. BGS Front Door Frailty https://www.bgs.org.uk/FrontDoorFrailty

  5. Get It Right First Time (GIRFT) Hospital Acute Care Frailty Pathway https://gettingitrightfirsttime.co.uk/wp-content/uploads/2023/06/Hospital-Acute-Care-Frailty-Pathway-FINAL-V1-June-2023-1.pdf

  6. Get It Right First Time (GIRFT)  and British Geriatric Society (BGS) 6 Steps to Better Care for Older People https://gettingitrightfirsttime.co.uk/wp-content/uploads/2023/07/GIRFT-BGS-Six-Steps-to-Better-Care-for-Older-People-FINAL-V2-July-2023.pdf

  7. NICE Guidelines on Falls in Older People https://www.nice.org.uk/guidance/cg161

  8. The Kings Fund - Social Prescribers https://www.kingsfund.org.uk/insight-and-analysis/long-reads/social-prescribing?gad_source=1&gclid=CjwKCAjw7NmzBhBLEiwAxrHQ-aM1KeeFEULQj7hVRzRuUvghN1gqig1jdAS78nIQOjEZ6HVLtB6_qxoCIxkQAvD_BwE

  9. Older adults experiences with ambulation during a hospital stay: A qualitative study https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7998512/#:~:text=Hospitalized%20older%20adults%20spend%20up,ambulation%20during%20their%20hospital%20stay.&text=Deconditioning%20effects%20of%20limited%20ambulation,to%20functional%20decline%20after%20discharge.

  10. Chris Wood @theADHDphysio on twitter www.x.com/theADHDphysio 

cwood twitter.png

S2E1 - Nutrition for Energy and Recovery

In this episode of the #theEDDMpodcast, we return to an ‘eat’ topic – nutrition and energy. I speak about the importance of adequate nutrition for energy production and recovery from illness, and how EDDM can help!

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Key facts:

  • The cost of treating a malnourished patient is two to three times more than treating a non-malnourished patient. It has been calculated that treating a non-malnourished patient amounts to £2,155, whereas treating a malnourished patient comes to £7,408 (1).

  • Healthcare facilities record the highest volumes of food waste compared with other types of collective catering, with food wastage ranging between 17% and 67% depending on the service system (2).

  • According to the NHS Eatwell Guide Starchy food should make up just over a third of the food we eat (3).

  • In the hospital diet, protein intake should be at least 1.0 g/kg actual BW/day. In case of illness, protein requirements may even be further increased, e. g. due to inflammation, infections, and wounds. Levels of 1.2 to1.5 g/kg BW/day have been suggested for older persons with acute or chronic illness and up to 2.0 g/kg BW/day in case of severe illness, injury, or malnutrition (4).

  • The Institute of Medicine suggests that 20-35% of your total daily calories should come from fats (5).

  • A systematic review and meta-analysis highlighted that exercise-nutrition interventions that start while patients are admitted to hospital and continue in the community/ posthospital, or, commence early postdischarge, appear to be effective in reducing frailty and some frailty-related physical indicators (6).

  • Nutritional intervention during hospitalization in medical wards is associated with reduced in-hospital mortality and reduced 30-day readmission rates as compared to the absence of nutritional support (7).

​

Resources:

  1. Malnutrition and the NHS https://hansard.parliament.uk/commons/2022-04-25/debates/9BA607B2-C2C7-4A70-B8C4-8BDC148B6BE9/MalnutritionAndTheNHS#:~:text=The%20cost%20of%20treating%20a,patient%20comes%20to%20%C2%A37%2C408.

  2. Hospital Services to Improve Nutritional Intake and Reduce Food Waste: A Systematic Review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9864175/#:~:text=Healthcare%20facilities%20record%20the%20highest,the%20service%20system%20%5B10%5D.

  3. NHS Eatwell Guide https://www.nhs.uk/live-well/eat-well/food-guidelines-and-food-labels/the-eatwell-guide/

  4. Protein Requirements in Critically Ill Older Adults https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5872796/#:~:text=It%20is%20important%20to%20note,protein%20per%20day%20%5B16%5D.

  5. Nutrition & Health Info Sheets for Health Professionals – Fat https://nutrition.ucdavis.edu/outreach/nutr-health-info-sheets/pro-fat#:~:text=According%20to%20the%20most%20recent,to%2035%20percent%20for%20children

  6. Effectiveness of combined exercise and nutrition interventions in prefrail or frail older hospitalised patients: a systematic review and meta-analysis https://bmjopen.bmj.com/content/10/12/e040146

  7. Malnutrition in Hospitalized Old Patients: Screening and Diagnosis, Clinical Outcomes, and Management https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8880030/#:~:text=Reduced%20consumption%20of%20hospital%20meals,of%20nutritional%20support%20%5B84%5D.

S2E2 - Urinary Tract Infections (UTIs)

In this episode of the #theEDDMpodcast, we return to a topic related to the ‘drink’ episode of EDDM which is Urinary Tract Infections. In this episode I speak about the importance of adequate hydration to avoid urinary tract infections, reducing unnecessary catheterisation and the impact that deconditioning can have on the urinary system in general during hospital admissions …and of course how EDDM can help!

 

Key facts:

  • Acute UTI occurs in up to 50% of women. Around 10–20% of women will experience a symptomatic UTI at some point in their lifetime, and often these are recurrent (1).

  • UTI is much less common in men who account for 20% of all occurrences (2).

  • Urinary tract infections are one of the most common infections acquired in hospitals, accounting for more than 30% of infections reported by acute care hospitals (3).

  • The NHS and UK Health Security Agency (UKHSA) report that data shows UTI’s led to more than 800,000 admissions to hospitals across the UK between 2018 – 2023 (4).

  • According to the Centres for Disease Control and Prevention (CDC), about 75% of UTIs acquired in the hospital are associated with a urinary catheter (5).

  • 15-25% of hospitalized patients receive urinary catheters during their hospital stay (6).

 

Resources:

  1. UTI (women) NICE https://cks.nice.org.uk/topics/urinary-tract-infection-lower-women/background-information/prevalence/#:~:text=UTI%20incidence%20increases%20with%20age,groups%20%5BUKHSA%2C%202019%5D.&text=Acute%20UTI%20occurs%20in%20up,lifetime%20%5BUKHSA%2C%202019%5D.

  2. UTI (men) NICE https://cks.nice.org.uk/topics/urinary-tract-infection-lower-men/background-information/prevalence/#:~:text=UTI%20is%20the%20second%20most,in%20people%20with%20a%20catheter.

  3. CDC information - UTI https://www.cdc.gov/infection-control/hcp/cauti/background.html#:~:text=Urinary%20tract%20infections%20are%20the,reported%20by%20acute%20care%20hospitals.&text=Virtually%20all%20healthcare%2Dassociated%20UTIs,instrumentation%20of%20the%20urinary%20tract.

  4. NHSE https://www.england.nhs.uk/2023/10/new-awareness-campaign-to-help-reduce-hospital-admissions-for-urinary-tract-infections/

  5. CDC information - CAUTI https://www.cdc.gov/uti/about/cauti-basics.html#:~:text=CAUTIs%20are%20one%20of%20the%20most%20common%20HAIs.,costs%2C%20and%20length%20of%20stay.

  6. CDC Information – preventing CAUTIs https://www.cdc.gov/uti/hcp/clinical-safety/index.html#:~:text=About%2075%25%20of%20UTIs%20developed,costs%20and%20length%20of%20stay.

S2E3 - Delirium with Leanne Keeley-Smith

In this episode of the #theEDDMpodcast, I’m joined by Leanne Keeley-Smith – a senior physiotherapist working at the QE hospital in Birmingham - to speak about the impact of deconditioning on delirium, the wider cognitive impacts, Leanne’s work as part of the Trust’s delirium working group, and how promoting EDDM principles can help!

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Key facts:

  • Delirium is defined by NICE guidelines as a change in a person’s mental state or consciousness that develops over hours or days. It may appear as confusion, difficulties with understanding and memory, or personality changes. Older people and people with dementia, severe illness or a hip fracture are more at risk of delirium (1).

  • Delirium can affect up to 1 in 3 hospital patients in the UK but is potentially preventable in about a third of these people (1). 

  • There are three main subtypes of delirium – hyperactive, hypoactive and mixed.

  • The 4AT is a well-recognised tool to screen for delirium (3). 

  • Catching and addressing delirium is essential. Approx 30-40% of cases could be prevented (4). 

  • Developing delirium is linked to worse outcomes in older people in the hospital, and it is associated with a higher risk of declining health and death (5). 

  • Delirium is an abrupt onset of reduced orientation to the environment in contrast to dementia, a gradual neurodegenerative process leading to the disturbance in the core features, and attention is affected much later in the disease course (6).

  • A range of conditions are associated with a higher chance of developing delirium, including (5):

    • Being hospitalized, especially in the intensive care unit

    • Older age, especially people age 80 and up

    • Dehydration

    • Malnutrition

    • Dementia

    • Parkinson’s disease

    • Infection, including meningitis, sepsis and others

    • Organ failure

    • Difficulty seeing or hearing

    • Multiple medications with mental or emotional side effects

    • Complex surgery with anesthesia, such as an open cardiac procedure

    • Hip fracture

    • Drug intoxication or withdrawal (including alcohol withdrawal)

    • Being on a ventilator or experiencing oxygen deprivation from any cause, including lung disease, opioid drugs or pneumonia

    • Low blood sugar or other metabolic disease

  • PINCH ME acronym to identify causes of delirium - Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment (7).

  • Leanne’s delirium prompt cards give staff a handy tool to refer to when caring for a patient with an acute change in cognition. Leanne has generated a card which can be attached to your ID Badge so you're never without! Using the 4AT to assess and identify delirium, the PINCH-ME tool to consider risk factors and causes, and the EDDM principles to treat and prevent delirium, Leanne has created a fantastic resource to improve delirium care (8).

 

Resources:

  1.  NICE Delirium guidelines https://www.nice.org.uk/guidance/cg103

  2. NICE Delirium information for public https://www.nice.org.uk/guidance/cg103/informationforpublic

  3. Diagnostic Test Accuracy of the 4AT for Delirium Detection: A Systematic Review and Meta-Analysis https://pubmed.ncbi.nlm.nih.gov/33076557/

  4.  Delirium in elderly adults: diagnosis, prevention and treatment https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065676/

  5. Delirium Johns Hopkins https://www.hopkinsmedicine.org/health/conditions-and-diseases/delirium

  6. Differentiating Delirium Versus Dementia in the Elderly https://www.ncbi.nlm.nih.gov/books/NBK570594/

  7. BGS End of Life Care in Frailty: Delirium https://www.bgs.org.uk/resources/end-of-life-care-in-frailty-delirium#:~:text=%27PINCH%20ME%27%20(Pain%2C,of%20delirium%20(see%20image).

  8. Contact Leanne for more information about her delirium prompt cards at leanne.keeley-smith@uhb.nhs.uk

  9. Leanne Keeley-Smith on twitter @LKSPhysio https://x.com/LKSPhysio

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S2E4 - Falls

In this episode of the #theEDDMpodcast, I speak about falls, multifactorial assessment of falls risk, the relationship between falls

and deconditioning…and how EDDM principles can help!

 

Key facts:

  • NICE define a falls as an unintentional event where a patient comes to rest on the ground, floor, or other lower level. A simple fall is defined as one occurring as a result of a chronic impairment of cognition, vision, balance, or mobility. It is distinguished from a collapse caused by an acute medical problem, such as an acute arrhythmia, transient ischaemic attack, or vertigo (1).

  • NICE guidelines suggest that Health and social care practitioners undertake a multifactorial falls risk assessment for older people who present for medical attention because of a fall, or refer them to a service with staff who are trained to undertake this type of assessment (1).

  • A multifactorial falls risk assessment may include the following (1):

    • identification of falls history

    • assessment of gait, balance and mobility, strength and muscle weakness

    • assessment of osteoporosis risk

    • assessment of perceived functional ability and fear relating to falling

    • assessment of visual impairment

    • assessment of cognitive impairment and neurological examination

    • assessment of urinary incontinence

    • assessment of home hazards

    • cardiovascular examination and medication review

  • As well as the multifactorial risks from NICE, inpatient falls can result from breakdowns within communication between staff members and with patients, inopportune environment for safe mobility, and a fear avoidance culture where fear of patients falling is a barrier preventing staff from mobilising patients (2).

  • Inaccurate fall risk assessment interpretations, where assessing the risk of falling in hospitalised patients could generate an unmeasured risk of immobility. In this context, when we “correctly” label the patient at risk of falling, we usually “incorrectly” immobilise them, to “correctly” follow the guidelines that we can certainly comply with “incorrectly.” (3).

  • Multiple studies are demonstrating that Increased mobility does not lead to increased risk of falls and there is a clear inverse relationship demonstrated between mobility levels and falls (2).

  • A study from America highlights that various programs to aid in the prevention of falls, including the use of chair/bed alarms, one-to-one and remote observation have been largely unsuccessful. These programs have not decreased the occurrence of falls; they were found to increase nursing stress, cause alarm fatigue, fear of litigation by nursing staff, and higher healthcare costs and financial penalties. This study went on to track patient mobility levels along with hospital fall occurrences during a set period of time between 2021 and 2022 and found that, when hospital-wide mobility levels were higher, falls per 1000 patient days were lower (2).

  • Positive risk-taking is an approach that encourages individuals, especially older adults or those with mobility issues, to engage in activities that challenge their physical abilities in a controlled and safe manner. This can help increase mobility and prevent falls by building strength, confidence, and functional abilities (4).

​

Resources:

  1. NICE Falls guidelines https://www.nice.org.uk/guidance/cg161

  2. Relationship between mobility and falls in hospital setting https://bpb-us-w2.wpmucdn.com/sites.brown.edu/dist/9/350/files/2023/08/82146-relationship-between-mobility-and-falls-in-the-hospital-setting.pdf

  3. The cognitive bias of immobility in inpatients at risk of falling  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10004290/

  4. Positive risk taking https://www.thegoodcaregroup.com/news/risk-and-reward-positive-risk-taking-clients/

S3E1 - Mouth Care

In this episode of the #theEDDMpodcast, we return to an ‘eat’ topic – mouthcare. I speak about the importance of oral hygiene, proper mouthcare and its links to deconditioning!

 

Key facts:

  • Aging itself causes a decline in oral function—the number of teeth, oral muscle strength and thickness decrease (1).

  • Impaired oral health, like tooth loss and subjective difficulties in eating, is shown to lead to functional decline, frailty, and disability with previous studies reporting an association between oral function and physical condition (1).

  • Approximately 71% of hospitalized rehabilitation patients and 91% of hospitalized acute care patients have impaired oral health (1).

  • Not brushing teeth and not removing secretions or coatings, increases the risk of a whole host of problems, including gum disease, tooth decay, and even systemic infections (2).

  • Oral bacteria can cause dental decay and gum disease. Dental decay is caused by bacteria metabolising sugar in the mouth and producing acid which causes cavities in the teeth over time. Dental decay is linked to the frequency of sugar consumption (3).

  •  Gum disease occurs when ineffective or absent tooth brushing leads to a build up of bacteria or plaque in the mouth. This develops on teeth which leads to inflammation of the gum and can affect the underlying bone leading to tooth mobility or loss and receding gums (3).

  • Oral bacteria can also be inhaled into the lungs where the bacteria colonises and increases the risk of aspiration pneumonia (3).

  • Hospital acquired pneumonia is really common and extends a hospital stay by over 1 week. HAP is the most common type of healthcare associated infection (HCAI), accounting for 21.4% of all infections acquired in the hospital setting. estimates suggest that in England each year 72,542 people develop HAP, with 15,072 associated deaths and 459,755 additional bed days. The estimated incidence risk was 4.2 per 1000 admissions (4).

  • Oral bacteria can also be absorbed into the blood stream and travel to other parts of the body. There is strong evidence linking gum disease and heart disease (3).

  • There is strong evidence of a bidirectional relationship between oral health and diabetes. Gum disease can lead to poor blood sugar control and poorly controlled diabetes can increase the severity of gum disease. People with diabetes are also at higher risk of developing dry mouth and oral thrush (3).

  • Research shows that oral care is often lacking in hospital and community care settings, especially to those patients who may be unable to carry out their own personal care and rely on others for support (5).

  • Health Education England - Mouth Care Matters programme (6).

 

Resources:

  1. Oral Management in Rehabilitation Medicine: Oral Frailty, Oral Sarcopenia, and Hospital-Associated Oral Problems - ScienceDirecthttps://www.sciencedirect.com/science/article/pii/S1279770723003834

  2. Oral health: A window to your overall health - Mayo Clinic https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/dental/art-20047475#:~:text=Most%20often%20the%20body%27s%20defenses,flow%20of%20spit%2C%20called%20saliva.

  3. Mouth Care Matters - Oral and general health animation https://www.youtube.com/watch?v=Ge9WGTp5y3o&list=PLrVQaAxyJE3eYeayCLSUFpxtkMxWmRo7L&index=6

  4. HAP_policy_project https://pcwww.liv.ac.uk/~dwootton/Policy/HAP_policy_project_2.pdf

  5. About the programme -Mouth Care Matters Improving Oral Health https://mouthcarematters.hee.nhs.uk/about-the-programme/index.html#:~:text=Poor%20oral%20health%20can%20lead,rely%20on%20others%20for%20support.

  6. Home - Mouth Care Matters https://mouthcarematters.hee.nhs.uk/index.html

S3E2 - Hypotension

In this episode of the #theEDDMpodcast, we return to a topic related to the ‘drink’ episode of EDDM which is Hypotension. In this episode I speak about the impact that both dehydration and general deconditioning can have on the circulatory and musculoskeletal systems, which can lead to hypotension, highlight the bidirectional relationship between the negative impacts of hypotension and deconditioning, and of course how EDDM can help to reduce all of this!

 

Key facts:

  •  When you are dehydrated, there is less blood travelling around the body. This can lead to low blood pressure, dizziness and fainting. In response, the heart may start beating faster (tachycardia) to help move blood around the body. You may experience this as a racing, pounding heartbeat in your chest, called palpitations (1).

  • Dehydration can also thicken the blood, increasing the risk of blood clots and heart attacks (1).

  • In healthy individuals, muscles are 70-80% water and that your bones are a 31% water (2)

  • Water brings calcium and other nutrients throughout the body, including to your bones. As your bones lose minerals and need to rebuild and strengthen, a lack of available calcium can lead to bone loss and eventually osteoporosis (3).

  •  Dehydration can also lead to a lack of lubrication of our joints which leads to achy, painful joints (4).

  • It is thought that 75% of the weight of the upper body is supported by the water volume that is stored in the disc core, 25% is supported by the fibrous materials around the disc (4).

  • The first BP should be taken after lying for at least 5 minutes. The second BP should be taken after standing in the first minute. A third BP should be taken after standing for 3 minutes. This recording can be repeated if the BP is still falling (5)

  • A positive result is: a drop in systolic BP of 20 mmHg or more (with or without symptoms), a drop to below 90 mmHg on standing even if the drop is less than 20 mmHg (with or without symptoms), or a drop in diastolic BP of 10 mmHg with symptoms (although clinically much less significant than a drop in systolic BP) (5).

 

Resources:

  1. Dehydration: signs, causes, and tips to drink more water | BHF - BHF https://www.bhf.org.uk/informationsupport/heart-matters-magazine/medical/signs-of-dehydration#:~:text=This%20can%20lead%20to%20low,in%20your%20chest%2C%20called%20palpitations.

  2. The effects of dehydration on the musculoskeletal system https://www.orthotx.com/post/the-effects-of-dehydration-on-the-musculoskeletal-system

  3. How Proper Hydration Affects Bone Health - Watauga Orthopaedicshttps://www.wataugaortho.com/2018/04/20/how-proper-hydration-affects-bone-health/#:~:text=As%20your%20bones%20lose%20minerals,water%20to%20carry%20them%20away.

  4. Dehydration and Musculoskeletal Pain - MT Physio Clinic https://www.mtphysioclinic.co.uk/hydration-and-musculoskeletal-pain/

  5. RCP Measurement of Lying and Standing Blood Pressure fffap_lying-and-standing-bp-procedure.pdf (rcp.ac.uk)

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