I4F: Isla for Frailty Feasibility Study

BACKGROUND: Older patients with frailty have complex support needs. How they manage with daily tasks such as eating and drinking, mobilising, communicating their preferences, and the level of support they need, can vary on a day-to-day basis. They are at risk of rapid loss of functional independence when they are acutely unwell. When older people need input from multiple different professionals, ineffective communication is sadly very common. This leads to disjointed care, and patients becoming frailer and suffering avoidable health complications. One of the problems is that it can be difficult for healthcare professionals to build up a complete picture of a patient from brief verbal handovers and written information in medical records. It is believed that video-recordings capturing the changing functional abilities and support needs of individual patients could improve care-provider communication and support for older people. Smartphones with cameras are now a part of everyday life, and people often tell their stories using photographs and videos. However, video recording patients during care delivery is not commonplace. It is not know how patients and carers feel about being video recorded or whether video recordings improve care.

AIM: To explore the perspectives of frail older patients, carers, and clinical staff around video recording during routine clinical care, and to understand how patient videos could impact on communication and care delivery across care transitions.

METHODS: The study team will recruit frail, older inpatients, their carers, and clinical staff from a Medicine for the Elderly ward. Over three months, doctors, nurses, and therapists will securely record and view patient videos alongside providing usual care. Videos will capture patients' functional abilities and support needs to inform ongoing assessment and care delivery. The investigators will collect information from patients/ carers/ doctors/ nurses /therapists about their experiences of the video recording intervention through interviews and questionnaires.

Around 10% of people aged over 65 years have frailty, rising to nearly 50% of those aged over 85 years, and frailty prevalence is expected to increase alongside the growth of the ageing population.

Older people with frailty commonly require input from multiple professionals across primary, secondary, and social care. Professional bodies including the British Geriatrics Society have advocated for responsible information sharing to ensure that older people with frailty are supported to age well. Yet, as patients move between different parts of the health and care service, communication between different professionals and different providers is frequently ineffective, assessments are duplicated, and carers are repeatedly asked to provide the same information. Poorly coordinated care is linked to avoidable complications, accelerated deconditioning, and loss of independence, as well as greater carer burden and increased costs to health and social care.

Much communication across professional and organisational boundaries takes place through written referrals and (increasingly) through shared electronic patient records. Electronic health records (EHRs) are voluminous, containing large quantities of unstructured text. This plethora of data, combined with variability in documentation practices and the propagation of erroneous information in the record, means clinicians face significant challenges retrieving information to support clinical assessment. Excessive time spent in the EHR system is known to be a major source of clinician dissatisfaction contributing to stress and burnout, but failure to retrieve relevant information can lead to medical errors and poor quality care. Moreover, while text is appropriate for communicating certain types of clinical information (for example, diagnoses, comorbidities, prescribed medications, allergies, etc), it is difficult to discern the nuances of a frail older patient's condition in relation to aspects such as functional ability, cognition, behavioural symptoms, and support needs from text narratives alone. Receiving professionals may be left wondering 'Is this normal for this patient?' It is vital that health and care professionals can recognise and track subtle changes to proactively manage avoidable deconditioning and deliver individualised, person-centred care. More sophisticated modes of documentation and communication are needed to improve patient assessment and care continuity across transitions of care.

In an age of smartphones, people are increasingly telling their stories using photographs and video recordings.Technological advances allow for a variety of video recording applications in healthcare but in practice these have largely been largely confined to research, education, and quality improvement. Researchers value the richness of video data that includes sound, environmental context, body language and facial expressions, thus facilitating objective, accurate documentation of behaviour. In medical education, video-recordings assist clinicians in recognising visual and auditory clues during clinical consultations that cannot be derived from text-based learning. Video-based surgical records have informed quality improvement initiatives through the provision of increased detail and nuance beyond what exists in written operative notes alone. A further clear advantage of video recording is the creation of a permanent visual patient record that can be reviewed repeatedly by multiple professionals, ultimately increasing the accuracy of clinical assessment and improving communication among multi-professional healthcare workers.

Nevertheless, ethico-legal concerns and patient confidentiality have historically limited the use of video-recording for direct care purposes. Early studies suggested that patients can feel censored or self-conscious in front of a camera and video recording can have a detrimental impact on the therapeutic relationship. However, over the last decade, the proliferation of smartphones had led to video recordings being captured in everyday life, and technological advances are supporting lawful collection, handling, and storage of visual data to protect people's privacy in line with data protection legislation.

Little is known about how video recordings can support the safety and quality of individual patient care. Members of the study team recently conducted a systematic review to explore use of video-recording patients for direct care purposes. Twenty-seven studies published in the last 10 years were identified, evaluating acceptability, effectiveness, and/or ethico-legal considerations associated with video-recording patients to support care delivery. The review also brought together key guidance and recommendations of professional and regulatory bodies in the UK relating to audio-visual recording in healthcare. Evidence suggests that video recording patients for direct care purposes may be acceptable to patients and professionals, providing that the benefits are clear and risks are properly mitigated. Video technologies have been piloted in a variety of different health and care contexts to support diagnosis, care, and treatment, however, no studies have examined the application of video-based patient records for supporting older people's care transitions. Furthermore, the extent to which video recording is effective in support direct patient care remains unclear due the small number of published studies and poor quality of existing evidence.

Video recordings could enhance the safety and quality of care transitions for older people with frailty through providing objective and richly detailed visual information about their functional capabilities, support needs, and care preferences. However, making and sharing patient video recordings raises important ethical and legal considerations that must be addressed to enable the practical application of video for direct care purposes. This study will explore the acceptability, feasibility, and potential effectiveness of embedding in the electronic patient record, video recordings captured during routine care.

A programme theory (below), developed by our multidisciplinary steering group and informed by national frailty policy, suggests how video-based patient records could lead to patient benefit.

Programme Theory

If (1) it were acceptable and feasible to video-record frail, older patients, capturing their functional abilities, support needs, and care preferences at key timepoints (e.g. hospital discharge), and (2) the video-recordings were available for view by all those assessing/caring for the person across primary/secondary/community settings,

Then (3) A shared understanding of the person's functional abilities and support needs could be created, (4) A longitudinal view of the patient's function could be visualised, (5) Communication during patient handovers/at care interfaces could be improved,

So that (6) Older people with frailty receive care that is more person-centred and joined up, (7) Deterioration of frailty status is recognised and act upon earlier, (8) Improvements in care delivery can be achieved in line with the NHS Long Term Plan and the NHS RightCare Frailty Toolkit

So that (9) Older people with frailty suffer less avoidable complications and spend less time in hospital when they don't need to be there, and (10) Older people's experiences of care and health outcomes can be improved.

Eligibility Criteria:
Patients.

Inclusion Criteria:

* Admitted as an inpatient to an acute Medicine for the Elderly ward at St Mary's Hospital during a 3-month pilot phase of Isla's visual record platform
* Aged ≥65 years old
* Are considered to be frail or pre-frail by the direct care team
* Have capacity to consent to study participation OR lack capacity to consent on the condition that a 'personal consultee' is available to advise on the patient's likely wishes and feelings about taking part.

Exclusion Criteria:

* Patients who lack capacity to consent will be excluded if a personal consultee is not available to advise on the patients' likely wishes or feelings about taking part.

Carers.

Inclusion Criteria:

* Aged ≥18 years
* Provide the patient/care-recipient with assistance in their daily activities and are unpaid for these caring activities
* Are willing to participate in an interview as part of the study
* A carer may be a member of the patient's family, a friend, or other person who provides the patient with unpaid care

Exclusion Criteria:

- Carers will be excluded if the patient/care-recipient declined to participate in the study

Ward team.

Inclusion Criteria:

* Clinical staff working on an acute Medicine for the Elderly ward at St Mary's Hospital.
* Staff must be working regular shifts on the ward during study initiation and pilot phases
* Staff must have an active nhs.net account.

Exclusion Criteria:

* Ad-hoc bank/agency staff
* Permanent staff on long-term leave (e.g. sick/maternity) during the pilot