If your assessment decided that contractures were likely; WHAT EXACTLY ARE THE PROTOCOLS TO PREVENT THAT? With no answer your research was woefully lacking in usefulness. LEADERS SOLVE PROBLEMS, DON'T JUST DESCRIBE THEM!
The Delphi of ORACLE: An Expert Consensus Survey for the Development of the Observational Risk Assessment of Contractures (Longitudinal Evaluation)
Abstract
Objective
Despite
rising prevalence rates, no standard tool is available to identify
individuals at risk of developing contractures. This study aimed to gain
expert consensus on items for the development of the Observational Risk
Assessment Tool for Contractures: Longitudinal Evaluation (ORACLE) for
care home residents.
Design
A two-round, online modified Delphi study.
Participants
Panellists
were qualified healthcare professionals with a background in
physiotherapy, occupational therapy, nursing, and rehabilitation
medicine.
Main outcome measures
In
the first round, the experts were asked to rate the predesigned list of
items on a Likert scale while in the second round, consensus was sought
in the areas of disagreement identified in the previous round.
Results
The
two rounds of the Delphi survey included 30 and 25 panellists,
respectively. The average clinical and academic experience of the
panellists was 22.2 years and 10.5 years, respectively. The panel
demonstrated a high level of consensus regarding the clinical factors
(10 out of 15 items); preventive care approaches (9 out of 10 items),
and contextual factors (12 out of 13 items) ranging from 70% to 100%.
Conclusion
This
Delphi study determined expert consensus on items to be included in a
contracture risk assessment tool (ORACLE). The items were related to
factors associated with joint contractures, appropriate preventive care
interventions, and potentially relevant contextual factors associated
with care home settings. The promise of a risk assessment tool that
includes these items has the capacity to reduce the risk of contracture
development or progression and to trigger timely and appropriate
referrals to help prevent further loss of function and independence.
Introduction
Contractures,
commonly defined as restrictions in the passive joint range, are
preventable but debilitating consequence of prolonged immobility,
eventually leading to structural abnormalities within the impacted
joint.1
This can lead to further deterioration in the limb and joint
flexibility and physical mobility, potentially leading to further
physical impairments, decreased independence with everyday activities,
and reduced quality of life.2,3
Contractures may vary from marginal restriction at a single joint to
severe limitations in the range of motion affecting several joints
simultaneously.4
Based on the severity of functional loss at a joint, contractures can
be categorised as (i) severe, (ii) moderate or clinically relevant, or
(iii) clinically non-relevant.5
The development of progressive joint contractures often follows an
insidious pattern, and their initial progression is neither painful nor
disabling. Joints only become painful when stretched beyond the point of
soft-tissue restriction. For this reason, contractures are often
unrecognised by individuals and their caregivers until they become
clinically relevant, that is, start interfering with daily functional
activities.6
Evidence suggests that individuals living in long-term care facilities are predominantly sedentary7; hence, they are at a higher risk of developing contractures.8
Long-term care settings demonstrate a considerable variation in the
prevalence of contractures spanning from 22% to 75% in at least one
joint.4,9–12 Contracture prevalence was found to be higher in the upper extremities compared with the lower extremities,4,10 with the shoulder and knees being the most commonly affected joints.4
When considering the impact of mobility on contracture development,
there is evidence that 70.5% of non-ambulatory care home residents
developed a contracture compared with the ambulatory group, which
developed none.13
Structured
risk assessments play an important role in referring patients to the
appropriate healthcare practitioner and enacting early treatment
strategies to reduce the risk of the condition progressing. In addition,
standard risk assessments are also vital to offer appropriate guidance
for risk protection and to have confidence in the tool being used.14
The need for a structured and systematic risk assessment of individuals
at risk of developing contractures has been identified in the
literature.15
Despite the reported high prevalence rates, there is a clear lack of a
standard, evidence-based measure that can actively identify individuals
at risk of developing contractures or worsening of existing contractures
in long-term facilities and trigger appropriate and timely referrals to
healthcare professionals.
The aim of the
current study was to systematically establish the components of
Observational Risk Assessment for Contractures: Longitudinal Evaluation
(ORACLE) for care home residents, based on multidisciplinary healthcare
expert consultation and consensus. The aimed users of the tool will be a
range of staff, including healthcare assistants and registered nurses,
who are the primary care providers in a care home. During the delivery
of care, their regular clinical observations are vital in order to
identify the individuals at risk of developing contractures. ORACLE will
potentially translate the clinical observations of the care home staff
in a systematic fashion, thereby ensuring consistency in identifying the
risk, calibrating that risk, helping them prescribe a set of actions in
response to the level of risk, and tracking subsequent changes in the
risk regularly.
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