Acute deterioration in care homes : exploring optimal approaches to the identification and management.

Abstract

When care homes residents experience an acute deterioration in their health status, they may receive care that is reactive and not in line with their preferences. The aim of this work was to explore how acute deterioration is managed in care homes, and to identify strategies to improve care. To achieve this, a multiple methods approach was employed. A repeated cross-sectional study showed that the complexity of resident care need is increasing, meaning that they are often living with many of the functional and physiological characteristics which would be used to recognise or indicate acute deterioration in other populations. An ecological study highlighted the susceptibility of residents to COVID-related mortality, its association with vital sign abnormalities at a population level, and the widespread use of the National Early Warning Score (NEWS2) in care homes. This is consistent with the policy drive to use remote monitoring and deterioration tools, especially NEWS2, in care homes. Qualitative work showed that the NEWS2 may have a useful role in managing acute deterioration, especially supporting carer judgement. However, implementation challenges, inconsistent uptake, and unintended consequences in this setting remain significant concerns. A quantitative study demonstrated that higher NEWS2 measurements (on hospital admission) were associated with adverse health outcomes. NEWS2 may therefore aid care decision-making for hospitalised residents, but its use in the care home setting remains unclear. A scoping review about deterioration tools demonstrated that the majority of studies described an intervention in which SBAR (situation-background-action-recommendation), NEWS2 or STOP AND WATCH was a component. Overall, there was no robust evidence that deterioration tools improve resident care, but there was evidence that tools can increase the confidence of care home staff in managing acute deterioration. The body of evidence presented in this thesis identifies important evidence gaps, and features of deterioration tools that should be prioritised for future development, such as supporting care home staff judgement and intuition about acute deterioration. A common theme throughout this programme of work is the implementation challenges of introducing novel deterioration interventions into care homes. Future research should be underpinned by implementation science theory with care homes residents and staff at the centre of intervention co-production.