Study On The Development And Implementation Of Practice Guidelines For The Management Of Frailty

Background Frailty is considered to be an important factor threatening human health.In the aging society,the prevalence of frailty is increasing.Frailty is highly correlated with many adverse events,leading to serious impact on the quality of life of older adults.It is reported that the medical expenses of the frail older adults are much higner than that of the non-frail older adults.Therefore,frailty will become an important source of healthcare and financial burden.The prevalence of frailty is high in China.Therefore,it is very important to implement scientific and effective frailty management measures to reduce frailty and the burden brought by it.However,the practice of the management of frailty in China is still at a preliminary stage and lacks scientific and standardized guidance.Guidelines are important basis for effective management of frailty.According to the existing evidence,a series of guidelines related to the management of frailty have been issued abroad,but there are still some limitations in guiding the practice in China.Coping with aging population has become a national strategy,and the support for health management and care in the aged also gradually increases,which provides rich soil for the development and application of guidelines for the frailty management in China.Therefore,it is necessary and feasible to develop practice guidelines for the management of frailty suitable for the medical situation in China.Objectives(1)To develop the “Practice Guidelines for the Management of frailty”,which is suitable for our country’s medical situation.Based on the integral conceptual model of frailty,the development of the guidelines was according to the existing guidelines,consensus,systematic reviews,and other studies related to the theme of this study,and also referred to the Chinese stakeholders’ values and preferences.(2)To conduct a polit implementation study under the guidance of the “Dynamic Pathway of Guidelines Implementation based on i-PARIHS Model” to evaluate the feasibility,appropriateness,and efficacy of the new guidelines,and to provide guidance and reference of the frailty management practice for medical staff in China.Methods Part 1 Guideline Development(1)Selection of problems and outcomes.We first made a preliminary list of the potential problems and outcomes related to the scope and purpose of the guidelines through literature review.Then,a two-round Delphi approach was used to invite experts to evaluate the importance of the contents of the list to establish the problems and outcomes ultimately included in the guidelines.(2)Evidence retrieval,evaluation and synthesis.For the problems and outcomes,we systematically searched,evaluated and synthesized the relevant guidelines and consensus,systematic reviews and other relevant studies on the management of frailty.We conducted methodological quality evaluations and evidence grading on the obtained evidence to provide evidence support for the formation of recommendations.(3)A qualitative study on the stakeholders’ values and preferences.The descriptive qualitative method and purposive sampling were used to select participants in the hospitals,nursing homes and communities in Changchun,China.The sample size was collected continuously until saturation occurred(18 frail older adults and 12 medical staff were finally interviewed).We used a qualitative content analysis method to perform data analysis.(4)Expert Meeting to form recommendations.We first drafted recommendations based on the best evidence retrieved and the stakeholders’ values and preferences.Then,using the method of expert meeting,8 experts and 2 family representatives were invited to determine the grades of recommendations,and to modify the content of the recommendations.(5)External expert review of the draft guideline.The first version of the guidelines was drafted based on the RIGHT list.We invited 10 external experts to review the first version of the guidelines by sending an email to evaluate the clarity,applicability,feasibility and scientificity of the recommendations and the guidelines.Part 2 Polit Implementation Study Convenience sampling method was used to select a nursing home in Changchun,China to carry out a pre and post control pilot study of guidelines implementation.In this study,the “Dynamic Pathway of Guidelines Implementation based on i-PARIHS Model” was used to guide the innovation.A total of 21 frail and pre-frail older people and 9 nursing practice participants participated in the study.The study was conducted from September 2022 to January 2023.(1)Clarify and Engage.Focus group interviews and inventory survey were used to identify problems.Then,the evidence was tailored to match and adapt to the context of innovation.An innovation team was formed.(2)Assess and Measure.The i-PARIHS Facilitator’s Toolkit was used to evaluate the three elements of i-PARIHS,namely,“Innovation/I”,“Recipients/R” and “Context/C”,to understand their characteristics.Audit criteria were determined based on evidence tailoring results.The method of site inspection and questionnaire survey were used to conduct baseline evaluate to identify the gap between evidence and practice.(3)Action and Implementation.We planned and implemented an appropriate program to meet the audit criteria based on the PDSA cycle.At the stage of “plan”(P),we analyzed barrier and facilitating factors from the three elements,and then an action plan was formulated accordingly.At the stage of “do”(D),we carried out a pre-test to understand the feasibility of the plan.At the stage of “study”(S),we adjusted the plan according to the feedback of the pre-test results.At the stage of “act”(A),the innovation program began in earnest.(4)Review and Share.We reassessed audit criteria to review the effectiveness of the program,and tried to spread,embed and sustain the innovation.Results Part 1 Guideline Development(1)Selection of problems and outcomes.The preliminary list included 21 problems and 22 outcomes.A total of 21 experts were sent questionnaires,and 20 experts(95%)finally completed two rounds of consultation.The finalized framework included five aspects: identification of frailty,interventions for frailty,management of other common symptoms/problems associated with frailty,comprehensive geriatric assessment and referral,covering a total of 23 problems and 7 types of key outcomes.(2)Evidence retrieval,evaluation and synthesis.A total of 6 evidence-based guidelines,1 consensus guidelines,1 expert consensus,25 systematic reviews and 22 studies were included.In addition,7 meta-analyses were made.On the whole,the methodological quality and evidence grading results of the included evidence were acceptable.Corresponding evidence has been retrieved for each problem,providing evidence support for the formation of recommendations.(3)A qualitative study on the stakeholders’ values and preferences.Four main categories for frail older adults were eventually generated,including: perception of frailty,attitude to frailty management interventions,health objectives,and influencing factors of intervention choice.Four main categories for nursing practice participants were eventually generated,including: perception of frailty,the significance and value of frailty management interventions,the promotion and hindrance factors of frailty management,and the expectation of frailty management.In general, stakeholders have insufficient awareness of the frailty and frailty management.Most stakeholders hold a positive attitude towards the frailty interventions in our guidelines,which provides localized references for the formation of recommendations.(4)Expert Meeting to form recommendations.We drafted 25 recommendations.By holding an on-site consensus meeting,the grades of recommendations were preliminarily determined,and recommendations were improved,from which the first draft of the guidelines could be written.(5)External expert review of the draft guideline.Based on the external review results,the guideline has been further improved,and the final version of the guideline was accomplished.The final version of the guideline includes five aspects: identification of frailty,interventions for frailty,management of other common symptoms/problems associated with frailty,comprehensive geriatric assessment and referral,with a total of 25 recommendations.Part 2 Polit Implementation Study(1)Clarify and Engage.Through group interviews with 6 key insiders,four main problems were identified,including the lack of knowledge and skills of nursing practice participants,the lack of responsibility consciousness of nursing practice participants,the lack of relevant systems and processes,and the low health level of older adults.Then,21 recommendations implementing in the innovation plan were determined by tailoring.An innovation team were formed in this stage.(2)Assess and Measure.The knowledge-attitude-practice level of frailty management was determined as the audit criteria at the recipients(nursing practice participants)level.The importance of frailty management and relevant rules and regulations determined as the audit criteria at the context level.The audit results showed that the knowledge-attitude-practice level of nursing practice participants was low,and the department did not carry out the work of the management of frailty.(3)Action and Implementation.At the stage of planning(P),the barrier and facilitating factors of the innovation were analysed,and the action plan were formulated,including developing the frailty management practice handbook,knowledge and skills training for nursing practice participants,a management plan for the frail older people,formulating trial rules and regulations for frailty management and purchasing frailty management equipment.At the stage of Do(D)and Study(S),the action plan was modified.The main modifications were as follows: on the one hand,the multi-component exercise was divided into several times according to exercise type to ensure that the older people had enough physical power and patience to complete the exercise plan;On the other hand,We Chat push of training content was added to the training plan.At the stage of action(A),the modified innovation plan began to be implemented.The audit criteria of the older adults were: frailty,cognitive function,depression and quality of life. (4)Review and Share.For nursing practice participants,after training and practice,the score of knowledge dimension(p=0.001),practice dimension(p=0.009)and total score(p=0.001)were significantly improved compared with the baseline score,while the change of attitude dimension was not statistically significant(p=0.83).For the frail older adults,after 12 weeks of intervention,the frailty score decreased significantly(p=0.002)and grip was significantly improved(p=0.001)compared with that before intervention.The number of older people in the stage of pre-frailty increased by 3 compared with that before intervention,the number of older people in the stage of frailty decreased by 5,and the number of robust people increased by 2.The GDS-15 score of the older participants decreased significantly(p=0.046),and the total score of SF-12 increased significantly(p=0.032);MMSE score,PCS dimension score of SF-12 scale(p=0.407)and MCS dimension score(p=0.079)did not change significantly.All 21 older people completed the baseline and 12-week assessment.The average attendance rate was 83%.No adverse events related to the interventions occurred.100% of the older people were satisfied with the project.At the context level,both the older people and nursing practice participants have gradually deepened their awareness and attention to frailty.In addition,the managers of the nursing home have provided support for the implementation of the innovation plan,such as purchasing equipment,establishing a working group,and formulating a temporary working regulation.Conclusions(1)The development of the Practice Guidelines for the Management of Frailty was based on the integrated conceptual model of frailty.The guideline was developed in sequence: selection of problems and outcomes by a two-round Delphi approach,evidence retrieval,evaluation and synthesis systematically,study on stakeholders’ values and preferences,on-site review of experts and external expert review.The results show that the formulation process of this guideline is scientific and rigorous,the framework items of the guidelines are clear,and the recommendations are appropriate.(2)After an innovation plan in a nursing care institution in Changchun,satisfactory results have been achieved at the level of personal and organizational context,further demonstrating the feasibility,appropriateness,and efficacy of the new guidelines,which provides practical reference of the management of frailty for medical staff in China.