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Most HAD research has focused on older people
(1–4). Falvey et al. described HAD as “declines in
muscle strength, muscle mass, cognitive function,
muscle protein synthesis and physical function” (2,
p. 1307), while van Vliet & Deeg describe it in terms
of loss of mobility (stairs, footpaths) and inability to
undertake activities of daily living (such as sit-to-stand,
moving around, and cutting toenails) (4). Creditor
described 8 hazards of hospitalization (including bed
rest or enforced immobilization) as: decline in muscle
strength and aerobic capacity; vasomotor instability;
reduced bone density; reduced pulmonary ventilation;
altered sensory “continence”, appetite and thirst; and
urinary incontinence (12). Compared with other aut-
hors in the field, Creditor reports the broadest range of
HAD attributes, and these were used to benchmark the
assessment items identified in this evidence scan (12).
HAD elements overlap those described for frailty.
Like HAD, frailty is also variably described in the
literature by characteristics such as decreased muscle
strength; fatigue; compromised ambulation, conti-
nence, nutrition, sleep patterns and/or energy levels;
heightened anxiety and/or depression; unexplained
persistent pain; and/or decreased confidence in safely
undertaking usual daily activities (1–7, 12). The main
difference between HAD and frailty appears to be the
time-frame within which change is detected. HAD can
manifest within hours of hospitalization requiring bed
rest or immobility (1, 2, 4, 6), whilst frailty is gene-
rally more insidious, taking longer for subtle age- or
disease-related changes to functioning to manifest (1,
5). Thus, the challenge of identifying HAD is ensuring
the repeated, judicious application of measures that
can efficiently demonstrate change within days of
hospitalization.
The term “body systems performance” is used in
this paper as an overarching term for a range of factors
addressed in the International Classification of Fun-
ctioning, Disability and Health (ICF), including body
functions and structures (such as weight, nutritional
status, cardiopulmonary condition, muscle strength,
skin integrity) and functional capacities (such as ba-
lance, transfers, walking ability, self-care) (13).
There are increasing pressures on acute hospital beds
worldwide, particularly given increases in the preva-
lence of chronic disease and the proportion of people
living for longer (2, 8–10). Safe, efficient and effective
discharge from hospital to home makes economic and
social sense (1, 2, 10, 12, 14, 15). Preventing HAD is
essential for safe, efficient discharge, and to prevent
readmission (1, 2, 6, 7, 8, 14). Therefore, being alert
to, and assessing for, incipient HAD should be within
the remit of any health professional (14, 16). Howe-
ver, there is no comprehensive agreed assessment for
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HAD that can be applied repeatedly during an acute
hospital admission (1–3, 5, 7, 8, 11–15). To be relevant
to an acute hospital admission, HAD assessment items
need to be measured at point-in-time (P-i-T) (or over
very short time-frames), so that incipient HAD can be
identified within days of admission.
To date, inpatient assessments of body system
performance are often inconsistently conducted by
different healthcare professionals, using different as-
sessment instruments, which assess different aspects of
body system performance over different time-periods
(2, 4, 12, 14–16). Moreover, findings are variably
recorded and shared, which constrains proactivity in
preventing HAD (11, 14–16). This largely reflects the
primary focus of acute hospitals, which is to resolve
the reason(s) for admission, rather than to prevent un-
suspected and adjunctive issues, such as HAD (14–16).
As a result, HAD may not be recognized until it has
become a risk to successful discharge. Hospital quality
standards and bed flow would be significantly enhan-
ced if regular application of core standard assessment
items for HAD occurred throughout the acute hospital
stay (1–3, 8–10, 14, 15). This paper describes research
to fill a current gap in clinical assessment practices for
HAD in acute hospital settings.
METHODS
Objectives
To systematically identify literature reporting on assessment
instruments relevant for incipient HAD during acute hospital
admissions; evaluate their psychometric properties; and identify
individual assessment items to form the basis of a comprehen-
sive, acute hospital test battery for HAD.
Research hypothesis
There is no standard, comprehensive instrument currently
available to assess acute hospital inpatients for all elements of
incipient HAD.
Research outcome
Identification of items from one or more psychometrically-sound
assessment instruments, to form the basis for comprehensive
testing of body systems performance to detect incipient HAD
during an acute hospital admission.
Study process
Papers that described psychometric properties of assessment
instruments for any element of HAD were systematically
identified. The psychometric properties and clinical utility of
these instruments were then critiqued using a validated checklist
(17); and assessment items relevant to a comprehensive test
battery for incipient HAD identified. The items must be able
to be repeatedly and efficiently applied and recorded by any
healthcare provider in acute hospital settings.